FUBUTEC 2004 -- Fax/Mail Registration Form

FUBUTEC

FUBUTEC 2004
Fontainebleau, France, 12-13 March 2004
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 MARCH 1ST. After March 1st, prices will be 10% higher.

REGISTRATION AND PAYMENT CONFERENCE REGISTRATION (Check appropriate boxes)
1. [ ] EUROSIS member 475 EURO Member Number:_____________________________	EUR ___________
2. [ ] Members of Sponsor or Affiliate Society 475 EUR Circle your affiliation: SISO	EUR ___________
3. [ ] Non-Member Participant 535 EUR	EUR ___________
4. [ ] Students, who are not authors but who wish to attend the conference, or ONE DAY PARTICIPANTS pay: 300 EUR	EUR ___________
(Above registration fees include, one copy of the PROCEEDINGS, all midday meals, cocktail, refreshments, coffees and social program,) One Day Participants and Non-Aothor Students cannot participate in the conference dinner.
5. [ ] Conference Dinner Ticket for Companion 60 EUR	EUR
6. [ ] Extra Conference Proceedings 40 EUR	EUR ___________
VAT Number if applicable: _______________________________
TOTAL AMOUNT DUE	EUR ___________
ADD BANK CHARGE of 15 EUR in case you pay by BANK or CHEQUE.	EUR ___________
TOTAL AMOUNT REMITTED	EUR ___________

[ ] 1)	Make payment by BANK TRANSFER to account No. 001-4081477-84 EUROPEAN TECHNOLOGY INSTITUTE, ETI Bvba, FORTIS BANK, Branch Office Ghent Centre, Kouter 6-8, B-9000 Ghent, Belgium IBAN CODE: BE03 0014 0814 7784, SWIFT CODE: GEBABEBB : 001-4081477-84 MENTION YOUR NAME and FUBUTEC'2004
[ ] 2)	Or pay by CHEQUE and send it to Philippe Geril, EUROSIS-ETI, European Simulation Office, University of Ghent, Coupure Links 653, B-9000, 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

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,
Coupure Links 653, B-9000 Ghent, Belgium
Phone: +32-9-2337790, Fax: +32-9-2234941