ACTE Executive Forum

Registration Form


All fields are required unless marked with a "*". Name, Title and Company will appear on badge as submitted.
Last Name, First Name
Title
Company/Affiliation
Address
Address*
City
State/Province*
Zip/Postal Code
Country
Telephone
Facsimile*
E-Mail
Registration Fee:	ACTE Member 210 EURO Non-Member 315 EURO Non-Member Joining 470 EURO
Payment:	Check American Express Diners Club MasterCard Visa
Cardholder Name
Card Number
Expiration Date
(Note: To pay by check, please do not submit this form on-line. Instead use your browser's print feature to print the completed form, make written note that a check has been mailed, and fax it to +32-2-743-1550. You should also print this form if you require a receipt of registration). You may submit this form online, by Fax: +32-2-743-1550 or Mail: ACTE Registration Office, Avenue Des Gaulois 7, B-1040 Brussels, Belgium. You may call +32-2-743-1589 for questions or more information. Full refund less a handling fee of Euro 50 per registrant will be granted to requests received in writing 1 week prior to the event. No refunds will be granted for requests after that date. telephone cancellations will not be accepted.