ACTE Executive Forum

Registration Form Bruxelles 20th January 2006 All fields are required unless marked with a "*". Name, Title and Company will appear on badge as submitted.
Name
Title
Company/Affiliation
Address
Address*
City
State/Province*
Zip/Postal Code
Country
Telephone
Facsimile*
E-Mail
Membership Number*
Registration Fee:
	ACTE and/or BATM corporate member plus one companion: complimentary Non-member corporate joining ACTE and BATM 400€ ACTE supplier member 300€ Non-member supplier joining and attending event 645€ For non-supplier joining BATM please visit www.batm.be
Payment:
	Check American Express Diners Club MasterCard Visa
Cardholder Name
Card Number
Expiration Date
This is a fully sponsored forum by BATM. ACTE sponsor benefits do not apply. Business industry will be checked at the time of registration. (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 1-262-763-7037. You should also print this form if you require a receipt of registration). You may submit this form online or by fax to 1-262-763-7037 or mail to, Attn: Registration, 111 S Pine Street, Burlington, WI 53105. For more information please email [email protected] or [email protected]. You may reach us by calling +33.1.47.68.16.54. (REFUNDS ONLY GIVEN ONE WEEK PRIOR TO FORUM.)