Refistration Form - UHasselt

Refistration Form

 
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 Register for the event (350 Euro, includes hotel and meals)
 Will take the bus on 22/04 at 16.30 in Liege train station
 Will take the bus on 25/04 back to Liege train station scheduled to arrive there at 16.00
   
  Registration will only be final up after we receive your payment:
Payment by bank transfer:
Name and address Accountholder:
Universiteit Hasselt
Agoralaan – Gebouw D
B – 3590 Diepenbeek
België

Bank: Fortis Bank
Bank address:
Ridder Portmansstraat 1
B – 3500 Hasselt
België
IBAN: BE77 0010 1870 7942
BIC (SWIFT) code: GEBABEBB

with indication of the
name of the participant and "WET – SYMPFOXCLO".