VIRTUAL WORLDS 98 CONFERENCE PAYMENT FORM Now please print out this form and mail (NOT EMAIL) 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: 2500 ________ or EARLY FULL REGISTRATION: 2000 ________ or NORMAL STUDENT REGISTRATION: 1000 ________ or EARLY STUDENT REGISTRATION: 800 ________ and optional BANQUET TICKET (subsidised): 250 ________ and optional EXTRA PARTNER (unsubsidised): 300 ________ and optional PEDAGOGICAL SESSION: 500 ________ REGISTRATION FEES TOTAL: ________ Please accept my payment by French cheque/Eurocheque/Bank draft (drawn on French clearing bank)/Credit Card as detailed below. All payments in French Francs payable to ASSOCIATION LEONARD DE VINCI. Any Eurocheque not to exceed maximum guaranteed, with card number on back. Visa/Mastercard are acceptable. Card type VISA/Mastercard/__________ Card No _____________________ Name on card: ____________________________________________________ Cardholders ______________________________________________________ Address*: __________________________________________________________________ __________________________________________________________________ Valid from date _______ 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 Tel: +33 01 41 16 75 71 Fax: +33 01 41 16 75 75