EUROMEDIA 2005 -- Fax/Mail Registration Form

EUROMEDIA 2005
Toulouse, France, 11-13 April 2005
FAX/MAIL REGISTRATION FORM
(or use the electronic form)

Please legibly print or type and fill out completely.

FIRST NAME	LAST NAME	M.I.
COMPANY OR AFFILIATION
Mailing address (tick one): [ ] HOME [ ] BUSINESS
STREET
CITY
ZIPCODE	COUNTRY
TELEPHONE	FAX
E-MAIL
DATE	SIGNATURE

PRICES VALID TILL APRIL 5TH. After April 5th, prices will be 10% higher.

REGISTRATION AND PAYMENT CONFERENCE REGISTRATION (Check appropriate boxes)
1. [ ] EUROSIS member € 485 Member Number:_____________________________	€ ___________
2. [ ] Members of Sponsor or Affiliate Society € 485 Circle your affiliation: SISO	€ ___________
3. [ ] Non-Member Participant € 545	€ ___________
4. [ ] Students, who are not authors but who wish to attend the conference, or ONE DAY PARTICIPANTS pay:€ 300	€ ___________
(Above registration fees include, one copy of the PROCEEDINGS, all midday meals, cocktail, refreshments, coffees and social program,) One Day Participants and Non-Author Students cannot participate in the conference dinner.
5. [ ] Conference Dinner Ticket for Companion € 50	€ ___________
6. [ ] Extra Conference Proceedings € 40	€ ___________
VAT Number if applicable: _______________________________
TOTAL AMOUNT DUE	€ ___________
ADD BANK CHARGE of € 15 in case you pay by BANK or CHEQUE.	€ ___________
TOTAL AMOUNT REMITTED	€ ___________

[ ] 1)	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
[ ] 2)	Or pay by CHEQUE and send it to Philippe Geril, EUROSIS-ETI, European Simulation Office, University of Ghent, Faculty of Engineering, Dept.of Industrial Management, Technologiepark 903, B-9052, Zwijnaarde-Ghent, Belgium.
[ ] 3)	Or pay by CREDIT CARD and fill in the information below:
	Charge my (tick one): [ ]Visa [ ] Euro/Mastercard [ ] American Express [ ]Diners CARD NO: __ __ __ __ : __ __ __ __ : __ __ __ __ : __ __ __ __ EXP.DATE: __ __ / __ __
	Authorizing Signature:
	Print Signature in CAPITALS

PURCHASE ORDERS ARE NOT ACCEPTED UNLESS GUARANTEED BY A CREDIT CARD NUMBER.

MAIL REGISTRATION FORM AND PAYMENT FORM COPY (1) / CHEQUE (2) / CREDITCARD INFO (3) 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