27 January 2015, NH du Grand Sablon, Brussels, Belgium

R E G I S T R A T I O N F O R M

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Please complete this form, provide credit card details and (e)-mail/fax to: AFCEA Europe, 105 rue Colonel Bourg, 1030 Brussels, Belgium, Tel: +32-2-705.27.31, Fax: +32-2-705.28.94, email:

Pre-registration with full payment is required prior to12January2015. After this date, we can no longer guarantee your registration.

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Photocopies acceptable. One registrant per form - attach business card or print using block letters

ALL FIELDS MUST BE COMPLETED

LAST NAME: ______FIRST NAME: ______MR./MRS./MS or RANK: ______

COMPANY / ORGANIZATION:______

The above information will be used to produce your badge but may be edited so as to fit on 3 lines of text.

JOB TITLE: ______ADDRESS: ______

POSTAL/ZIP CODE: ______CITYSTATE: ______COUNTRY: ______

TEL: ______FAX: ______E-MAIL: ______

BILLING ADDRESS: (if different from participant's address above) CONTACT NAME: ______

CONTACT EMAIL: ______COMPANY / ORGANIZATION:______

ADDRESS: ______

POSTAL/ZIP CODE: ______CITY & STATE: ______COUNTRY: ______

DATA PROTECTION: the above data will be used for AFCEA internal purposes only.

My company has a VAT (Value Added Tax) number NOYES, the number is below:
(country of VAT registration and of billing address must be the same):
IMPORTANT INFORMATION
All fees are in Euros and subject to Belgian VAT at 21%.
  • NATO personnel and some Diplomatic Missions may be exempt from VAT charges but must provide a VAT Exemption Certificate otherwise VAT will be charged. This document has to be provided with registration form.

Tick the appropriate boxes AFCEA or ESRT Member Non-AFCEA or Non ESRT Member
Fees include training course and material,
Business lunch, a reception on 27 January
and refreshments during the coffee breaks.
€500 €600

Subtotal = EUR______

Add VAT (21% of Subtotal) = EUR______

Total Registration Fee = EUR______

Cont’d. page 2

27 January 2015, NH du Grand Sablon, Brussels, Belgium

R E G I S T R A T I O N F O R M (Page 2)

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PAYMENT DETAILS:

Payment must accompany completed registration form.

Confirmation will be emailed when payment is received, accompanied by a “paid” invoice for accounting/VAT (tax)purposes.

All registrations will be processed on a first-paid, first-served basis.

I am a Member of: AFCEAESRT

Membership # ______(must be completed to receive discount)

If you would like to join AFCEA to benefit from the member rate at this event, please contact AFCEA International eforereturning your registration form. You may join on line at

If you would like to join ESRT to benefit from the member rate at this event, please contact:

>.

Credit Card: debit my credit card for a total amount: ______

Amex Visa Mastercard Eurocard number is:

Cardholder name: ______Expiration date: ______Signature: ______

Cancellation policy: 15% administration costs will be charged for cancellations prior to 12January2015 - no refund after that date.Name substitution: at any time.