MESM'2004 6TH MIDDLE EASTERN SIMULATION MULTICONFERENCE Fax Registration Form

MESM'2004

Registration Form

FAX/MAIL REGISTRATION FORM
(or use the electronic form)

Please legibly print or type and fill out completely.

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

REGISTRATION AND PAYMENT (PRICES VALID TILL SEPTEMBER 10TH) A.CONFERENCE REGISTRATION (Check appropriate boxes)
1. [ ] EUROSIS member EUR 485 Member Number:_____________________________	EUR ___________
2. [ ] Participant from the Middle East EUR 300	EUR ___________
3. [ ] Non-Member Participant EUR 545	EUR ___________
4. [ ] For registration AFTER September 10, add EUR 50	EUR ___________
5. [ ] Students, who are not authors but who wish to attend the conference pay: EUR 175	EUR ___________
(Above registration fees include, one copy of the PROCEEDINGS, all midday meals, cocktail, refreshments, coffees and social program, except for non-author students where the Conference Proceedings are NOT INCLUDED.)
6. [ ] Conference Dinner Ticket for Companion EUR 40	EUR ___________
VAT Number if applicable: _______________________________
TOTAL AMOUNT DUE	EUR ___________
ADD BANK CHARGE of (EUR 15) 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 MESM 2004
[ ] 2)	Or pay by CHEQUEand send it to Philippe Geril, ETI-EUROSIS, European Simulation Office, Ghent University, Coupure Links 653, B-9000, Ghent, Belgium.
[ ] 3)	Or pay by CREDIT CARDand fill in the information below:
	Charge my (tick one): [ ]Visa [ ] Euro/Mastercard [ ] American Express [ ]Diners CARD NO: __ __ __ __ : __ __ __ __ : __ __ __ __ : __ __ __ __ EXP.DATE: __ __ / __ __
	Authorizing Signature:

PURCHASE ORDERS ARE NOT ACCEPTED UNLESS GUARANTEED BY A CREDIT CARD NUMBER.
CREDIT CARDS EXPIRING THE MONTH OF REGISTRATION ARE NOT ACCEPTED.

MAIL REGISTRATION FORM AND PAYMENT FORM COPY (1) / CHEQUE (2) / CREDITCARD INFO (3) TO:
Philippe Geril, ETI-EUROSIS
European Simulation Office, Ghent University,
Coupure Links 653, B-9000 Ghent, Belgium
Phone: +32-9-2337790, Fax: +32-9-2234941