EEWC 2012: CONFERENCE REGISTRATION FORM EEWC-2012 - Conference M77A12 Complete and return to Mrs. Everdine Volkers, Delft University of Technology Faculty of Technology, Policy and Management, Department of Systems Engineering: [email protected] OR Fax: +31 (0)15 2783429

The name and title given here will be printed on your badge and participants’ list.

1. Participant Information

Title:  Prof.  Dr.  other:______ Mr.  Ms.  Mrs.

Full name : ______

Affiliation/Country : ______

The registration fee is as follows: Event Fee Conference fee (Monday/Tuesday) 300 Euro Before May 1, 2012 Conference Dinner (Monday) Included in the conference fee Industry Track (Tuesday) Included in the conference fee Doctoral Consortium (Wednesday) Included in the conference fee (if not registered for the conference, the DC fee alone is 100 Euro) Doctoral Consortium dinner (Thursday) Included in the conference and/or DC fee Design Science Research AND Special Topics Included in the conference and/or DC fee Presentations/Demonstrations (Thursday)

2. Payment Methods

Use any of the following methods for conference or DC registration fee payment. If you need a VAT number use: NL001569569B01.

A: Credit Card: I authorize Delft University of Technology (Finance) to charge my credit card with the amount of … Euro. Cardholder : ______Credit card number : ______Expiration date : ______CVC code : ______

B: Bank Transfer (important: in the transfer, mention your name and this code: M77 M90351): The bank fees must be paid by the customer for both payer and payee so that Delft University of Technology can receive the full amount. Name of Bank : ABN AMRO Address of Bank : Coolsingel 119, 3012AG Rotterdam, The Netherlands Account Number : 54.28.91.859 IBAN / SWIFT code : NL08ABNA0542891859 / ABNANL2A Account name : TU Delft Faculty of Technology, Policy & Management

C: Cash on the Site: Registration fee can be also paid cash on the site provided you sent this registration form by email before May 1 and commit for the payment upon your arrival at the conference.

IMPORTANT: Please note that NO refund on any service mentioned above will be issued as all the services are ordered and paid when the registration is received. By sending in this registration form, I acknowledge that I commit myself to the immediate payment of the full conference fee. I have taken notice of the cancellation terms on this form.

Date: ______/______/______

Full Name:______

Signature: ______