Design of Experiments Conference Antwerp Please complete this form and press the submit button at the bottom. You will receive a confirmation of your registration per email. Personal information Title: Mrs. Mr. First Name: (*)   Last Name: (*)   Email Address: (*)     Affiliation: (*)   Department: Street: (*)   Zip/Postal: (*)   City: (*)   Country: (*)   Phone Number: (*)   Fax Number: Registration Fee (please choose one option) (*) Early bird registration (before December 21) PhD student: 50 euro Other: 125 euro Late registration (after December 21) PhD student: 75 euro Other: 175 euro Conference dinner Would you like to participate to the dinner on January 14 (fully sponsored by SAS)? (*) yes no   If yes, would you like a vegetarian meal? yes no Payment (*) Wirement Credit card   Privacy (*) The conference organizers will prepare a list of participants. Would you like your email address to appear on that list? yes no   Remarks/special requests The registration fee should be paid either by VISA/MASTERCARD/EUROCARD or by wire. The details for wiring the fee are given below. For payment by credit card, the form at http://www.ua.ac.be/main.aspx?c=.DOE&n=57633 has to be completed and faxed to ++32 3 220 48 17. For payments by wire, the transactional details are as follows: Bank account number 735-0079975-35 IBAN: BE57 7350 0799 7535 BIC: KREDBEBB The bank's address is KBC, Rubens KBC Toren, Eiermarkt 20, 2000 Antwerpen. When wiring the fee, it is crucial that you provide the following information along with the above information: "SC200732 + your name".