THIS IS NOT THE MAIN REGISTRATION FORM. THIS FORM MAY BE SUBMITTED AS COMPLIMENTARY TO THE MAIN REGISTRATION FORM.

Title: Prof. Dr. Mr. Mrs.

First Name: Middle Initial: Last/Family Name:

Company/Institution:

Address:

Province/State: Country: Zip/Postal Code:

E-mail: IEEE Membership #:

Tel: + ( ) Fax: + ( )

Country code Area Code Number Country code Area Code Number

Please let us know if you have any disability:

All Fees are in Euro (€) and all taxes are included

ADDITIONAL ITEMS / Amount / Subtotal
Early
(By August 6th) / Onsite
(after August 7th) / Quantity
Proceedings / 25 / 25
Welcome Reception Ticket / 30 / 40
Banquet Ticket / 70 / 90
Lunch Ticket (seated buffet) / 18 / 18
Lunch Ticket (lunch box) / 10 / 10
Tutorial / 25 / 35
Airport Transfer
Departure times from airport to Hotels
(Please circle your preferred time) / 15 / 15
26th August / 06:30 / 09:20 / 17:50 / 22:45
27th August / 06:30 / 09:20 / 17:50 / 22:45
28th August / 06:30 / 09:20 / 17:50 / 22:45
Total Amount for Additional Items: / €
SATELLITE WORKSHOPS / Amount / Subtotal
Early
(By August 14th) / Onsite
(after August 15th) / Quantity
Satellite workshop / 100 / 120
Satellite workshop (for registered attendees) / 50 / 70
Satellite workshop (for students) / 80 / 100
Total Amount for Satellite Workshops: / €
TOTAL AMOUNT: / €

CANCELLATION AND REFUND POLICY: Before July 20, 2017: 100% refund less € 100 administration fee. No refunds after July 21, 2017.

Please check. I have read and accepted the cancellation terms mentioned above and on the EUSIPCO 2017 web site.

METHOD OF PAYMENT – CHECK ONE ONLY

By Bank Transfer (Please add EURO 20,00, as handling fee. The total must be net of all bank expenses)
Please scan and email this form () and you will be sent an e-mail with the necessary bank account details. Please provide us with a valid email address.

By Credit Card. Please circle one: MasterCard / VISA

I authorize you to charge my credit card with the amount of Euro:

Card Number: Expiry Date:

Cardholder’s Name (In case the registrant is not the card holder, please email also a copy of both sides of the credit card):

ID validation number (The last 3 digits of the number that can be found on the back side of your credit card) :

Cardholder’s Signature: Date:

EUSIPCO 2017 Registration Desk

e-mail: