REGISTRATION FORM B

! REGISTRATION DEADLINE: FRIDAY SEPTEMBER 27 !

Please completely fill in the form below, print it, place your signature or that of the official credit card holder (in black ink!) at the bottom of the form and fax it (around the same time as sending your online registration form A) to + 32 - 9 - 264.64.99. If you would be so kind not to leave any blank space between the digits of your credit card number. 

If you choose to send your registration form by regular mail but do not have an original registration form (enclosed in the second announcement), you can also fill in this registration form B, print it, place your signature and send it to the Conference Secretariat.

Family name: Initials: Male Female

Title/Profession:

Institution/Company:

Postal address:

                     

City/ZIP code:

Country:

Phone: Fax:

E-mail:


                                                                                                               Total

Registration fees        before July 15, 2002    220,00 (Euro)

                               after July 15, 2002      250,00 (Euro)            (Euro)

    !!! AFTER JULY 15, ONE CANNOT REGISTER AT THE RATE OF 220 (EURO) ANYMORE !!!

Conference activities    I will be participating in the    yes    no

                                   pre-conference workshop

                                   (49,00 Euro)                                                (Euro)

 

                                           I will be attending the          yes    no

                                   conference banquet

                                   with * accompanying person(s)

                                   (49,00 Euro per person)                                 (Euro)

                                   (* fill in how many - if any - persons will be accompanying

                                   you at the conference banquet, not counting other

                                   conference participants!)

 

                                      TOTAL PAYMENT IN EURO ():                    (Euro)

 

I will be attending the welcome reception    yes    no

(included in registration fee)

 


Method of payment

    Please record "P9723, SICDS - <name participant>" on all methods of payment

    Make international money orders and cheques payable to: UNIVERSITEIT GENT,

    SICDS CONFERENCE, Sint-Pietersnieuwstraat 25, Ghent, Belgium

Credit card

        Eurocard/Mastercard    VISA    American Express    Diners Club

         Charge credit card number: Card expiry date:

         (make sure you correctly fill in a 16 digit credit card number)

         Name official card holder: 

International money order to 001-1950612-18 of FORTIS BANK, Warandeberg 3, Brussels, Belgium

    (make sure to give your financial institution the payment order around the same time

    as your registration)

Registered bank cheque (personal or company cheques cannot be accepted)

    (please enclose the cheque with a completed and signed registration form to be sent

    to the Conference Secretariat)

   DATE:                            SIGNATURE: ___________

                                            (of official card holder)