Registration

ICATM'99 Registration Form Please mail the complete Registration Form to : Pascal LORENZ / ICATM'99 IUT/GTR - 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 03 65 80 42 Email : lorenz@colmar.uha.fr

Title: _______ First Name: _____________ Last Name: ______________________

Institution: ___________________________________________________________

Street Address: ________________________________________________________

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

Phone: ____________________________ Fax: ______________________________

Email : ____________________________

Arrival Date : ____ June 1999 at _____
Departure Date : ____ June 1999 at _____

Conference Registration Fees:

The Full registration fees include: attendance to the Conference, coffee breaks, 3 lunches, the gala dinner and the preprints.

Academic rate:

IEE, IEEE, SEE Member 2400 FF _________ FF
(Membership # __________)

non member 2600 FF __________ FF

Industry rate: 4000 FF __________ FF

Additional Conference Proceedings (FF 400): __________FF

Additional Gala Dinner (FF 300): __________FF

Total French Francs .............. _________

Payment of Fees:

__ By Foreign Check in French Francs to "Office du Tourisme de Colmar".

__ By Bank Transfer to: Caisse d'Epargne d'Alsace, Avenue de la République, 68000 Colmar - France. Bank code: 16705 - Counter code: 09017 - Account number: 04100568821 - Key: 23 - Account name: Office du Tourisme de Colmar - Transfer Swift : BFCE FR PP 317

__ By Credit Card:
     __ Mastercard
     __ Visa
     __ American Express

Card number: _________________________
Expiration date: _________

Signature: