2009 Ada-Belgium Membership Application ________________________________________________________________________ Please mail to or fax to -------------- --------- Ada-Belgium vzw/asbl + 32 (0)2 650 56 09 c/o Universite' Libre de Bruxelles (ULB) Boulevard du Triomphe Campus de la Plaine, CP 212 B - 1050 Bruxelles, Belgium Page 1 of _______ Personal Information -------------------- Name __________________________ First name _________________________ For Corporate Members: Name of Appointed Contact Person Job title / Occupation ________________________________________________ Company / Institution _________________________________________________ Address _______________________________________________________________ ________________________________________________________________________ Zip code ______________________ City _______________________________ Country _______________________ E-mail _____________________________ Telephone _____________________ Telefax ____________________________ The above address is ___ my company address ___ my private address Membership (Includes Ada-Europe Membership & Benefits Package) ---------- (Please tick one item) ___ Individual Member (annual fee: 30 EUR) ___ Corporate Member (annual fee: 130 EUR) ___ Student Member (annual fee: 15 EUR) Payment information (Please tick one item) ------------------- I agree to pay the appropriate registration fee to Ada-Belgium vzw/asbl ___ to account number 409-9054291-64 (KBC) mentioning "2009 Ada-Belgium Membership" Info for international payments by bank transfer: Bank Identifier Code (BIC): KREDBEBB International Bank Account Number (IBAN): BE29 4099 0542 9164 Ada-related Points of Interest ------------------------------ If you have any specific point of interest, please mention them in attachment to this form. Additional Addresses -------------------- If you know other people or companies in Belgium who are interested in Ada, please mention their names and addresses in attachment to this form, and we will contact them with information on Ada-Belgium. Thank you. Signature _________________________ Date ___________________________
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Find out about the Ada-Belgium membership benefits.
Last update: 2008/12/16.
Dirk Craeynest