VIRTUAL WORLDS 2000 CONFERENCE PAYMENT FORM Now please print out this form and mail/fax it to ASSOCIATION LEONARD DE VINCI with the payment. Name _____________________________________________ Address __________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Email ____________________________________________ Online form done YES / NO Phone _____________________ Fax __________________ Signed ____________________ Date _________________ REGISTRATION FEES (FF) NORMAL FULL REGISTRATION: 3000 ________ or EARLY FULL REGISTRATION: 2500 ________ or NORMAL STUDENT REGISTRATION: 1000 ________ and optional EXTRA BANQUET TICKET: 300 ________ and optional EXTRA COPY VW2000 PROCEEDINGS: 350 ________ and optional EXTRA COPY VW98 PROCEEDINGS: 350 ________ REGISTRATION FEES TOTAL: ________ Please accept my payment by French cheque/Bank draft (drawn on French clearing bank)/Credit Card as detailed below. Visa/Mastercard are acceptable. All payments in French Francs payable to ASSOCIATION LEONARD DE VINCI. Card type VISA ___ or Mastercard ___ Card number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Name on card: ____________________________________________________ Cardholders ______________________________________________________ Address*: __________________________________________________________________ __________________________________________________________________ Expiry date: __ __ / __ __ __ __ Amount FF ______________________ Cardholders signature ____________________________________ Date ______________ *Must be address credit card bill is sent to. THE COMPLETED FORM SHOULD BE MAILED TO: INSTITUT INTERNATIONAL DU MULTIMEDIA POLE UNIVERSITAIRE LEONARD DE VINCI 92916 PARIS LA DEFENSE CEDEX FRANCE OR FAXED TO: +33 (0)1 41 16 75 75 OR EMAILED TO: Jean-Claude.Heudindevinci.fr