Medieval and Renaissance Music Conference, Brussels, 6-9th July 2015 Payment form In order to finalize your registration for the International Medieval and Renaissance Music Conference 2015, please fill in and sign this form and send it to Anne-Sophie Fayt fayt.annesophie@gmail.com If you are a student or jobless, please send proof (such as a student card) Participant’s data First name Surname Affiliation Email address Conference registration fee (total) Credit card ☐ Visa ☐ American Express ☐ Mastercard Card number Expiration date (M/M/YY) Card Security Code (last 3 digits on reverse of card) Holder’s name (as on card) Signature ☐ Diners Club If you prefer, you can pay with a bank transfer to the following account. In this case, please send a proof of payment to Anne-Sophie Fayt fayt.annesophie@gmail.com Name of the beneficiary : Information : IBAN : BIC : ULB « 4.R00.B.000162 Inscription » followed by your name BE79 2100 4294 0033 GEBABEBB