2002 Ada-Belgium Membership Application ________________________________________________________________________ Please mail to or fax to -------------- --------- Ada-Belgium + 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 = 1 210 BEF) ___ Corporate Member (annual fee: 130 EUR = 5 244 BEF) ___ Student Member (annual fee: 15 EUR = 605 BEF) Payment information (Please tick one item) ------------------- YES, I agree to pay the appropriate registration fee to Ada-Belgium VZW ___ to account number 409-9054291-64 (KBC) mentioning "2002 Ada-Belgium Membership" 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 ___________________________ Attachment ____________________________________________________________
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Find out about the Ada-Belgium membership benefits.
Last update: 2002/01/05.
Dirk Craeynest