Registration Form

 

  

London, England
9 September 2004



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

 

Registration Fee:

 

ACTE Member 175 EURO
Non-Member 350 EURO
Non-Member Joining 450 EURO
Complimentary
       ( If registering as a comp, please include "code")

 

Payment:

 
Check
American Express
Diners Club
Eurocard/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 32.2.743.15.50. You should also print this form if you require a receipt of registration.)



You may submit this form online by Fax: 32.2.743.15.50 or Mail: ACTE EMEA, Avenue des Gaulois, 7 - B-1040 Brussels. You may call 32.2.743.15.89 for questions or more information.