PWC'05 Registration Form
Please mail the complete Registration Form to :
Pascal LORENZ / PWC'05
University of Haute Alsace - IUT - 34 rue du Grillenbreit - 68008 Colmar, France
Phone : 33 (0)3 89 20 23 66   Fax : 33 (0)3 89 20 23 59   Mobile: 33 (0)6 32 63 02 04
Email : lorenz@ieee.org

Title: _______ First Name: _____________ Last Name: ___________________________

Institution: _______________________________________________________________

Street Address: ___________________________________________________________

City: __________ State: ____________ Zip: ___________ Country: ________________

Phone: _________________ Fax: ___________________ Email : ____________________

Arrival Date :        ________ at __________ with Flight N°: ________

Departure Date :    ________ at __________ with Flight N°: ________

Conference Registration Fees

The full registration fees include: attendance to the conference, the coffee breaks, the lunches, the gala dinner and the proceedings

	Non Member	IEE-IEEE-SEE, Member
Academic Rate Membership #	500 €	450 €	______ €
Industry rate Membership #	700 €	650 €	______ €
Additional Paper Conference Proceeding: 90 €	______ €
Additional Gala Dinner: 60 €	______ €
Additional extra pages (100 € per page)	______ €

Total Euros:  _________

Payment of Fees:

__ By Foreign Check in Euro to "Agent Comptable de l'Université de Haute Alsace".

__ By Credit Card
     __ Mastercard
     __ Visa
     __ American Express
Card number: _________________________
Expiration date: _________
Security Code: _________
(The security code is the set of last 3 digits in the reverse side of the Card)

Holder's Name : ____________________
Date and Signature: