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Registration Form Matpost 2011.doc

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Registration Form Matpost 2011.doc
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MATPOST'2011 4th European Conference on HV & MV Substation Equipment 23 - 24 November 2011, Lyon, France Please complete and return this form to: SEE, 17 rue de l'Amiral Hamelin - 75783 PARIS CEDEX 16 - France Tel.: +33 (0)1 56 90 37 11 - Fax: +33 (0)1 56 90 37 08 - E-mail: HYPERLINK "mailto:congres@see.asso.fr" congres@see.asso.fr On-line registration is advised via the Conference Website HYPERLINK "http://www.matpost2011.org" www.matpost2011.org Registration Form Please use BLOCK CAPITALS when filling in this form Family Name: FORMTEXT ????? First Name (s): FORMTEXT ????? Title (Prof, Dr, etc....) : FORMTEXT ????? Job position : FORMTEXT ????? Company : FORMTEXT ????? Address : FORMTEXT ????? Zip code : FORMTEXT ????? City : FORMTEXT ????? Country : FORMTEXT ????? Email : FORMTEXT ????? Tel : FORMTEXT ????? Fax : FORMTEXT ????? Registration to Matpost 2011 Rates before October 23rd VAT incl Rates from October 24th VAT incl Non member registration FORMCHECKBOX 695? FORMCHECKBOX 780? Member* registration FORMCHECKBOX 620? FORMCHECKBOX 695? Academic non member registration FORMCHECKBOX 450? FORMCHECKBOX 530? Academic member registration FORMCHECKBOX 395? FORMCHECKBOX 450? Phd Student registration** (Gala Dinner not included) FORMCHECKBOX 350? FORMCHECKBOX 350? Gala Dinner only for Phd student registration (Optional) FORMCHECKBOX 80? FORMCHECKBOX 80? Amount to be paid FORMTEXT ????? FORMTEXT ????? * Individual Members of SEE and all other organisations which have sponsored the conference. ** Gala Dinner is not included in the Phd Student registration. Matpost 2011 registration fee includes : Conference admission, Conference bag and program, CD Rom proceedings, lunches, Coffee Breaks on November 23rd and 24th 2011, the Gala dinner of November 23rd except for phd student. FORMCHECKBOX I will attend the gala dinner FORMCHECKBOX I will not attend the gala dinner Payment FORMCHECKBOX Check in Euros made payable to SEE / Matpost 2011 FORMCHECKBOX By bank transfer in Euros made payable to ``SEE / Matpost11'' with no charge for the beneficiary (please attach a copy) Bank Address: BNP Montparnasse Ent. (00274), Bank # 00274, Bank code # 30004, Account # 00010336242, RIB code 58, IBAN code : FR76 3000 4002 7400 01033624258, BIC : BNPAFRPPPAA FORMCHECKBOX Credit Card FORMCHECKBOX Visa FORMCHECKBOX Euro/Mastercard FORMCHECKBOX American Express I hereby authorise the SEE to charge my credit card to the amount of : FORMTEXT ????? Last 3 digits at the back of credit card : FORMTEXT ????? Card n?. FORMTEXT ????? Cardholder's name: FORMTEXT ????? Expiry date: FORMTEXT ????? Date: FORMTEXT ????? Signature: FORMTEXT ????? v oe l a P R ? | A O - * , . j- . 0 6 F L N b d f p r t v '' ? ? ? ? j'' c r (R) ? ? ? A AE E E TH a a i i o oe jl ja " $ 8 : < < F H L N P R l ? ? | | ? 3/4 A ? O ? o th ph ph hb Registration by purchase order is possible. To do so, return this registration form together with the purchase order to SEE by mail or by fax at + 33 (0) 1 56 90 37 08. Any cancellation must be sent to SEE before November 1st 2011 upon written notice only. After this date the full conference fee will be payable and no refund will be possible. Please note that registration cannot be made by telephone or email. For further information regarding the registration, please contact the Matpost 2011 Conference office: HYPERLINK "mailto:congres@see.asso.fr" congres@see.asso.fr Merci de completer ce formulaire et de le retourner a : Please complete and return this form to: SEE, 17 rue de l'Amiral Hamelin - 75783 PARIS CEDEX 16 - France Tel.: +33 (0)1 56 90 37 11 - Fax: +33 (0)1 56 90 37 08 Societe de l'Electricite, de L'Electronique et des Technologies de l'Information et de la Communication Association reconnue d'utilite publique par decret du 7 decembre 1886 - Siret 785 393 232 00042 - APE 9412Z N? Identification FR 44 785 393 232 17 rue de l'amiral Hamelin - 75783 Paris cedex 16 - HYPERLINK "http://www.see.asso.fr" www.see.asso.fr