Please complete this form and return to the INTERTANKO London Office

attn. Mr Phillip Blanshard

for payment via credit card via fax: +44 207 977 7011

for payment via cheque or bank transfer via email:

A registration confirmation will be sent upon receipt of payment.

DELEGATE INFORMATION
Capt./Mr./Mrs./Ms./Miss/Dr./Other (please state):
Family Name: / First Name:
INTERTANKO Full Member / INTERTANKO Associate Member / Non-Member
Company Name: / Position:
Address:
City: / Postal Code: / Country:
Telephone: / Fax:
Email is required for confirmation of registration / E-mail
REGISTRATION
INTERTANKO Members / Dinner (10 May) @ US$ 225 / Partner at Dinner @ US$ 225
Partner’s Name:
Chartering Seminar (11 May) @ US$ 325
Chartering Seminar (11 May) & Dinner (10 May) @ US$ 500
Non Member / Dinner (10 May) @ US$ 300 / Partner at Dinner @ US$ 300
Partner’s Name:
Chartering Seminar (11 May) @ US$ 375
Chartering Seminar (11 May) & Dinner (10 May) @ US$ 650
Any Dietary Requirements:
METHODS OF PAYMENT - All remittances should be free of bank charges & commissions.
Please charge my credit card*:
VISA / Mastercard / Eurocard / American Express
Creditcardno: / Expiry Date:
Card Holder’s Name:
CVC-Number (3-digit number on back of the card) / Total Amount: / USD
Date (dd/mm/yy): / / / Signature:
I enclose my cheque for USD / made payable to 'INTERTANKO'.
Cheques should be sent to INTERTANKO, Attn Accounts, Postbox 761 Sentrum, N-0106 Oslo, Norway.
I have paid USD / into INTERTANKO's bank account
Account Name: INTERTANKO; Account No. 83960441497; IBAN: NO8483960441497; SWIFT CODE: HANDNOKK. Bank Details: Handelsbanken A/S, Postboks 277 Skoyen, N-0212 Oslo, Norway.
* All transactions will be made in USD, with exception of American Express Credit Cards - these are charged in Norwegian Kroner at the rate prevailing on the day when the transaction is made.
** Cancellations need to be in writing addressed to . An administrative cancellation fee of US$ 75 (dinner) / US$ 100 (seminar) will be charged for any cancellations received after 15 April 2012.

INTERTANKO: Leading the Way; Making a Difference