REGISTRANT INFORMATION
Title: Dr.
Mr.
Ms.
Mrs.
Student
Name:
Company/University:
Address:
Address2:
City, zip code and country:
Telephone:
Fax:
Email:
Payment:
Payment can be done by credit card or bank transfer:
Credit Card
Bank Transfer
Credit Card:
Please charge my credit card with the total amount above:
Visa
Eurocard/Mastercard
Diners
American Express
Card number:
Card expiration date (ie. 01/02):
Cardholder's name, if different from above:
By checking this box, I am hereby
granting my authorized signature for the above charges to the select credit card.
Date:
Bank Transfer:
Transfer the total amount above to account number 54.28.91.611 of TU Delft, Faculty ITS, Delft, stating IWH-i53898, via ABN AMRO Bank, Delft, the Netherlands (SWIFT code ABNANL2A).
Hotel reservation, guaranteed until April 15, 2001: hotel Zuiderduin, Egmond aan Zee
Accomodation: single room (Dfl. 150/night)
double room (Dfl. 210/night)
Date of arrival:
Date of departure:
Payment must be paid directly to the hotel at departure. Prices include breakfast, tourist tax will be added.
Cancellation: must be received in writing (email/fax/letter). Refunding of the registration fee mins Dfl 150 administration costs will be given until May 01, 2001. After May 01, the registration fee is non-refundable.
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