For security reason, only printed form can be used. Thus, fill, print and mail/fax this form and payment to: Mme Sylvie Barrouquere, ADERMIP, 3 Avenue Didier Daurat, 31400 Toulouse France Phone:+(33)5 62 47 49 89 -Fax:+(33)5 61 80 81 75 - E.mail:barrouqu@cict.fr

Last Name First Name

Company/University

Business Address

City State/Country Zip Code

Phone Fax

IEEE/IEEJ Member No (Required for member rates):

Check off registration type desired	Registration categories	Advance by April 1st	Late/Onsite	Total due (specify FF or Euro )
Conference Technical Session Fees cover: admission to the conference, conference proceedings and CDROM, coffee breaks, lunches, welcome reception and banquet.	Member IEEE/IEEJ	2500 FF/381 Euro	3000 FF/457 Euro
	Non Member	3000 FF/457 Euro	3500 FF/533 Euro
	Student	1300 FF/198 Euro	1500 FF/228 Euro
Total Registration Fee Due
Miscellaneous	Additional Tuesday Banquet Ticket	600 FF/91 Euro
	Additional Technical Digest	450 FF/68 Euro
Total Miscellaneous Due
TOTAL ENCLOSED

Payment Method

I enclose a Check drawn on payable to ADERMIP

I enclose a Bank Draft payable to ADERMIP -Account n ° 12719500200 Banque Courtois,branch reference Agence 10268,Toulouse Remusat, 31000 Toulouse,France (bank identification 02504 key 49)

Creditcard: CB: Visa: MasterCard/EuroCard:

Card Number: Expiration date

I enclose a Purchase Order (French Residents only)

Signature: Date:

An invoice will be sent in return.