EUROMEDIA'2005 -- Electronic Registration Form

EUROMEDIA'2005
Toulouse, France, 11-13 April 2005
ELECTRONIC REPLY FORM
(or use the fax/mail form)

ELECTRONIC REGISTRATION FORM
Please note: This form does NOT work with Internet Explorer 3.02 or lower.
It does work fine with all versions of Netscape and higher versions of IE

Title
First Name:
Surname:
Occupation and/or Title:
Affiliation:
Mailing Address:

Zipcode:
City:
Country:
Telephone:
Fax:
E-mail:

Yes, I will attend the 2005 EUROMEDIA conference.

A. Conference Registration. (Fill in 1/2/3/4 and 5/6/7 if necessary) - PRE-CONFERENCE PRICES VALID TILL APRIL 5TH. After April 5th, prices will be 10% higher.

1. EUROSIS Conference Member € 485
EUROSIS member number:
2. Member of Sponsor or Affiliate Society € 485
Affiliation Society:	SISO
3. Non-Member participant € 545
4. Students who are NOT authors or a ONE DAY registration € 300
5. Extra Conference Dinner ticket for companion. € 50
6. Extra Conference Proceedings € 40
7. Add bank charge if necessary when paying by bank transfer or cheque € 10
TOTAL AMOUNT TO PAY IN €

B. PAYMENT INFORMATION

I will make payment by BANK TRANSFER to account No. 001-4081477-84 European Technology Institute,
ETI Bvba, FORTIS BANK, Branch Office Ghent Centre, Kouter, B-9000 Ghent, Belgium
IBAN CODE: BE03 0014 0814 7784, SWIFT CODE: GEBABEBB : 001-4081477-84 MENTION YOUR NAME and
EUROMEDIA 2005 (make a print of this form so you know what you submitted) and ADD A COPY OF PAYMENT TO THIS FORM

I will pay by CHEQUE and send it to Philippe Geril, EUROSIS-ETI, European Simulation Office, Ghent University,
Faculty of Engineering, Dept.of Industrial Management, Technologiepark 903 , B-9052, Zwijnaarde-Ghent, Belgium.
(make a print of this form so you know what you submitted)

I will pay by CREDIT CARD but do not send the information with the form. Please phone me for the credit card information

I will pay by CREDIT CARD and fill in the information below. Please note: credit card information is NOT encrypted YET in the e-mail.
If this is a problem: fax the credit card information separately, or discuss the payment information with Philippe Geril by phone or by e-mail.

Type of card
Card no
Cardholder name
Exp.Date

If e-mail fails, you can also print this information and send / fax it to:
Philippe Geril, EUROSIS-ETI,
European Simulation Office, Ghent University,
Faculty of Engineering, Dept.of Industrial Management,
Technologiepark 903 , B-9052, Zwijnaarde-Ghent, Belgium.
Phone: +32-9-264.55.09, Fax: +32-9-264.58.25