2012 Ada-Belgium Membership Application
________________________________________________________________________

Please mail to                                  or fax to
--------------                                  ---------
   Ada-Belgium vzw/asbl                            + 32 (0)2 650 56 09
   c/o Universite' Libre de Bruxelles (ULB)
   Boulevard du Triomphe
   Campus de la Plaine, CP 212
   B - 1050 Bruxelles, Belgium                         Page 1 of _______


Personal Information
--------------------
Name  __________________________   First name  _________________________
For Corporate Members: Name of Appointed Contact Person
Job title / Occupation  ________________________________________________
Company / Institution  _________________________________________________
Address  _______________________________________________________________
________________________________________________________________________
Zip code  ______________________   City  _______________________________
Country  _______________________   E-mail  _____________________________
Telephone  _____________________   Telefax  ____________________________

The above address is  ___  my company address
                      ___  my private address

Membership  (Includes Ada-Europe Membership & Benefits Package)
----------                               (Please tick one item)
___  Individual Member  (annual fee:  35 EUR)
___  Corporate Member   (annual fee: 135 EUR)
___  Student Member     (annual fee:  15 EUR)

Payment information                      (Please tick one item)
-------------------
I agree to pay the appropriate registration fee to Ada-Belgium vzw/asbl
___  to account number 409-9054291-64 (KBC)
mentioning "2012 Ada-Belgium Membership"

Info for international payments by bank transfer:
Bank Identifier Code (BIC): KREDBEBB
International Bank Account Number (IBAN): BE29 4099 0542 9164
Bank address: KBC, Havenlaan 2, B-1080 Brussels, Belgium

Ada-related Points of Interest
------------------------------
If you have any specific point of interest, please mention them in
attachment to this form.

Additional Addresses
--------------------
If you know other people or companies in Belgium who are interested
in Ada, please mention their names and addresses in attachment to
this form, and we will contact them with information on Ada-Belgium.
Thank you.


Signature  _________________________   Date  ___________________________

Also available as a PDF file or an OpenOffice document.

Find out about the Ada-Belgium membership benefits.

To the Ada-Belgium home page.

Last update: 2012/01/08.