Registration on-line for CHAOS Membership
CHAOS asbl, Dr. Ir. Daniel M. DUBOIS,
Institut de Mathématique, B37, Université de Liège,
Grande Traverse 12,
B-4000 LIEGE 1, Belgium.
Fax: +32 (0)4 3669489
E-mail: Daniel.Dubois@ulg.ac.be
http://www.ulg.ac.be/mathgen/CHAOS/
The annual fee for CHAOS Membership is 25 euros.
Fill the fields of this form, and click on SUBMIT to send your CHAOS Registration by email,
or print this form and send it by post mail or fax.
I am interested TO BECOME A NEW ADHERENT MEMBER of the non-profit association CHAOS
I am interested TO REMAIN AN ADHERENT MEMBER of the non-profit association CHAOS
Here are my personal data (fields in red are obligatory):
REALNAME (First, Middle, Last names):
EMAIL:
Date of Birth:
Title/Position:
Institution:
Department:
Street, nr:
Town:
Country:
Tel (Office):
Tel (Home):
Fax:
Web:
I register for CHAOS Membership in completing this form :
I register for CHAOS Membership, for ...... (number of) year(s) : .... , 2009, 2010, 2011, 2012, ... The total fee : ... (number of years) x 25 euros/year = ....... euros Please send an INVOICE to the following address : ................. ...................................
I pay by cheque.
I pay by Bank to
CHAOS ACCOUNT IBAN BE50 3400 6169 9718, BIC-code ING Belgium (ING Swift address): BBRUBEBB, Banque Bruxelles Lambert (Avenue du Centenaire 1, B-4053 Embourg, Belgium - Tel + 32 4 361 66 30 - Fax + 32 4 365 21 25).
I pay by Post to
CHAOS ACCOUNT IBAN BE22 0001 1095 3347, BIC-code POSTCHEQUE : BPOTBEB1, bpost, Banque de la Poste, Embourg, Belgium.
I pay by CREDIT CARD (a credit card form is available on the web).
Date Signature