First Name : *

Last Name : *

Position :

Titles and Qualification :

Email : *

Phone number : (please include country area code)

Institution :

Address :

Postal code :

Town and country :

Invoice address :

Tax ID (optional) :

Registration

The registration fee covers sessions, coffee breaks, lunches, welcome party and abstract book.

EVSSAR member

Early Reg (until March 15^th) :_ 160 €__ , Regular (after March 15^th) :_ 200 €

Non-EVSSAR member

Early Reg (until March 15^th) :_ 200 €__ , Regular (after March 15^th) :_ 240 €

Student

Students have to certify their position by Student ID card or Dean Letter

to be faxed to n° 003210418280.

Early Reg (until March 15^th) :_ 80 €__ , Regular (after March 15^th) :_ 90 €

Welcome Party (Friday evening 14th)

Free ! (Included in registration fee)

Gala Dinner (Saturday evening 15th). Only 130 seats available !

___40 €__ Nr of persons : __Total euro :

Hotels

In order to organise efficiently the shuttle service, Please indicate in which Hotel you are staying .

Please remember : the shuttle buses will leave from these four hotels only !

Please indicate one Holiday Inn Brussels Airport NH Hotel Brussels Airport Thon Hotel Brussels Airport Ibis Brussels Airport None of these *

Number of persons who are not registered and will take the shuttle with you to Louvain-La-Neuve :

Financial details:

Payment may be made by credit card or bank transfer. (Please check box accordingly)

I choose to pay by Bank Transfer :

Statement :

I paid  Euro: by bank transfer to EVSSAR account number 068-2231329-65   DEXIA Bank

IBAN: BE18 0682 2313 2965      BIC (SWIFT): GKCCBEBB

All bank charges are at sender expense. Please indicate your Name!

I choose to pay by Credit Card :

Please debit my Credit Card : Visa : Mastercard :

Credit card number :

Expiry date (mm/yy) :

Name of the Holder :

CVC code (3 or 4 digit code)

The three-digit number at the back of your card at the right side of your credit card number

Total amount paid : Euro :

Date (dd/mm/yy):

Please note : Cancellation fee:

Complete refund of fees paid if requested before April 30th, 2010.

25% of total fees paid withheld if requested after April 30th, 2010.