registration form

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3 – 5 September 2007, Göteborg, Sweden
REGISTRATION FORM
MAIL OR FAX COMPLETED FORM TO:
Chalmers Univ. of Technology
Att: Ewa Wäingelin, CSE Dept.
SE-412 96 Göteborg, Sweden
Fax: +46 31 772 3663
PERSONAL INFORMATION
Please use the writable PDF form (or print out the PDF and fill in the form using block letters).
Name: ____________________________________________________________________________________
Last/Family Name
First/Given Name
Mr. Ms Dr. Prof.
INQUIRIES
E-mail: patmos07@ce.chalmers.se
Phone: +46 31 772 1692
Fax: +46 31 772 3663
__________________________________________________________________
Organization/Affiliation: _____________________________________________________________________
Postal address: ____________________________________________________________________________
Zip code: __________________ City: __________________________________________________________
Country:__________________________________________________________________________________
Daytime phone: ______________________________Fax: _________________________________________
E-mail: ___________________________________________________________________________________
Dietary needs: Vegetarian Other (please specify): _________________________________________
Do not include my name, mailing/e-mail address, phone/fax numbers on a published list of attendees.
ACCOMPANYING PERSON(S)
Family name: __________________________________ First name: _________________________________
Family name: __________________________________ First name: _________________________________
Accompanying person dietary needs: Vegetarian Other (please specify): _________________________
MEMBERSHIP INFORMATION
(Membership numbers must be provided to receive member rates)
IEEE Member No. ____________________
Non-Member
Full-time Student (A copy of a student photo ID & IEEE student membership is required with the registration form. )
P.T.O.

Please print
Family name: __________________________________________
First Initial: ________________________
REGISTRATION WORKSHOP FEE IN EURO (EUR)
Early registration IEEE member 475 €
By 24 June, 2007 Non member 525 €
(excl. VAT) Student 400 €
Late registration IEEE member 550 €
After 24 June, 2007 Non member 600 €
(excl. VAT) Student 450 €
VAT 25%
Additional Proceedings
VAT included - applies to all
Pre-Conference Tour
VAT included – applies to all
Accompanying persons
VAT included– applies to all
Please see VAT conditions
Sub Total €
60 €
Sunday 2 Sep. 2007 95 €
Pre-Conference Tour 95 €
Banquet Dinner 95 €
3-day luncheon ticket 60 €
REGISTRATION GRAND TOTAL EUR
Amount to pay
in EUR
The registration fee for
delegates includes
• admission to workshop and
poster sessions
• a copy of the proceedings
• daily coffee and lunches
• welcome reception and
banquet dinner
Note
Without pre-registration On-site
availability is not guaranteed
VAT should be added if:
• registration fees are paid by
non-taxable entities such as
institutions/organizations etc
and private persons within the
EU
• registration fees are paid by
participants or companies
within Sweden
• you are an accompanying
person
Please state your VAT registration number: _________________________________
(Valid for participants within the European Union only, in order to pay the workshop fee,
excl. VAT.)
SOCIAL PROGRAM
Welcome Reception (free of charge for PATMOS participants) YES NO
Banquet Dinner (free of charge for PATMOS participants) YES NO
Accompanying person(s)
Welcome Reception (free of charge)
PAYMENT INFORMATION
Number of persons: ___
All payment should be made in EUR and made out to Chalmers tekniska högskola AB,
ref: PATMOS’07. Mark your payment with your name. Please indicate which of the
following means of payment you have used.
Cancellation
Cancellation of registration and
social events will be accepted
until 24 June, 2007. The total
amount will be refunded, less
EUR 100 for administrative
expenses. No refunds can be
made for cancellation received
after 24 June, 2007. Please
also see ’General Information’
on the workshop homepage.
Please note
Unfortunately we cannot accept
Euro cheques, company
cheques or personal cheques.
Bank Account No. 3055 77 11371 Swift Code NDEASESS
IBAN: SE26 3000 0000 0305 57711 371, Bank name: Nordea Bank Sverige AB, SE-405 09 Göteborg
Plusgiro : 4589358-3 (Only for Swedish participants) Bankgiro: 5946-1830 (Only for Swedish participants)
Chalmers’ participants only: Kst _________ Project no _____________ Activity no____________
Visa
Master/Eurocard
Credit card No: I__ I __I __I __I __ I __ I __I __I __I __I __I __I __I __I __I __I __I __I
Security code: I __ I__ I__I With expiry date (month/year): I__I __I _/_I __I __I __I __I
(last 3 digits of the number in the signature panel on the back side of the card)
Having signed below, I hereby confirm that I have read and I am fully aware of the cancellation conditions stipulated under ’General
Information’ on the workshop homepage. I hereby authorise Chalmers Univ. of Technology to charge this credit card account for
the total amount due. I also consent to Chalmers Univ. debiting or crediting my credit card account for any subsequent change(s) to
the items booked. Credit cards will be charged in SEK based on the current EUR/SEK exchange rate.
Date __________________
Cardholder´s name ___________________________________________________
Signature _________________________________________
Chalmers VAT NO. SE556479559801