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 |
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E-MAIL |
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DATE | SIGNATURE |
A. | CONFERENCE REGISTRATION | |
1. | BASIC REGISTRATION FEE SCS or AFFILIATE MEMBERS.
Please, tick all boxes that apply. Member of: [ ] SCS [ ] Eurosim [ ] CASS [ ] JSTT [ ] | [ ] BF 20.000
[ ] ECU 500 |
2. | IF YOU ARE NOT AN SCS OR AFFILIATE MEMER: ADDITIONAL FEE
(Fees include all lunches, coffees, conference dinner and conference proceedings) | [ ] BF 2.000 [ ] ECU 50 |
VAT Number if applicable: | ||
REGISTRATION FEE DUE | BF___________ | |
ADD BANK CHARGE of BF 350 (9ECU) in case you pay by BANK or CHEQUE. | BF___________ | |
TOTAL AMOUNT REMITTED | BF___________ |
[ ] 1) | Make payment by BANK TRANSFER to account No. 290-0033837-05 SCS Europe BVBA, SOCIETE GENERALE DE BANQUE, Branch Office Ghent Centre, Kouter 6, B-9000 Ghent, Belgium MENTION YOUR NAME and Euromedia'96 |
[ ] 2) | Or pay by CHEQUE and send it to SCS European Office, 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:
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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: SCS European Office,
European Simulation Office, University of Ghent, Coupure Links
653, B-9000, Ghent, Belgium.
FOR OFFICE USE ONLY:
Paper Code: |
Number of Pages: |
Date entered on Registration File: |
Status Entered: |
Reg Memo: |
AF Memo: |