GAME'ON 2004 -- Electronic Registration Form

GAME'ON 2004
Ghent, Belgium, 25-27 November 2004
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 2004 GAME'ON conference.

A. Conference Registration. (Fill in 1/2/3/4 and 5/6/7 if necessary) - PRE-CONFERENCE PRICES VALID TILL NOVEMBER 20TH. After November 20th, prices will be 10% higher.

1. EUROSIS Conference Member EUR 475
EUROSIS member number:
2. Member of Sponsor or Affiliate Society EUR 475
Affiliation Society:	SISO
3. Non-Member participant EUR 535
4. Students who are not authors or a ONE DAY registration EUR 300
5. Extra Conference Dinner ticket for companion. EUR 50
6. Extra Conference Proceedings EUR 40
7. Add 21% VAT (Value Added Tax)
8. Add bank charge if necessary when paying by bank transfer or cheque EUR 10
TOTAL AMOUNT TO PAY IN EUR

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 6, B-9000 Ghent, Belgium IBAN CODE: BE03 0014 0814 7784, SWIFT CODE: GEBABEBB : 001-4081477-84 MENTION YOUR NAME and GAME'ON 2004 (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, Coupure Links 653, B-9000, 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,
Coupure Links 653, B-9000 Ghent, Belgium
Phone: +32-9-2337790, Fax: +32-9-2234941