Med Ren 2015 payment form ENGLISH 2

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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
[email protected]
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
[email protected]
Name of the beneficiary :
Information :
IBAN :
BIC :
ULB
« 4.R00.B.000162 Inscription » followed
by your name
BE79 2100 4294 0033
GEBABEBB
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