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IMOB

Universiteit Hasselt - Knowledge in action

REGISTRATION + PAY FORM - ICTCT (NOVEMBER 8-9 2012)

 
  Sex : Male   Female (*)
  First name : (*)
  Last name : (*)
  Street : nr : bus : (*)
  Postal code :  City:  (*) 
  Country : (*)
  E-mail : (*)
Don't enter more than 1 email address. You will shortly receive
a confirmation email, also check your spam folder.
  Phone :
  Fax :
  Professional affiliation :
  VAT-number :
 Registration - more info
   Profile: (*)
ICTCT member- country category A  
ICTCT member- country category B  
ICTCT member- country category C & D  
Non-member country category A  
Non-member country category B  
Non-member country category C & D  
Student   (confirmation via student ID required)

after early-bird registration date – 22/10/2012 |
+ 50 euro all profiles


  I will attend the informal meeting
  and reception on November 7: (*)
Yes   No   


  Conference dinner: (*)

I will not attend the conference dinner  
Yes, I will attend the conference dinner  
Yes, I will attend the conference dinner and will bring a partner  (+ 50€)

  I will take part in the social
  programme: (*)
I will not take part in the social programme   
Yes, I will take part in the social programme   (+ 40€)
Yes, I will take part in the social programme and will bring a partner   (+ 40€ per person)

  Total amount to be paid : euro

  Invoice required: (*) Yes    No

  Payment method : Bank transfer   Online Payment   (*)


(*)mandatory fields