Registration Form

 

  
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 - 43 Euro
Non-Member - 86 Euro
Non-Member Joining - 340 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.