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