VMA - Online Membership Registration

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First name:

Last name:

Company:

Title:

Email:

Mobile:

Phone:

Address:

City:

State/Province:

Zip/Postal code:

Country:

Choose the Membership type suitable for your company:

Membership type	Annual Fee
Company Annual Turnover < €500,000	€ 2,000
Company Annual Turnover > €500,000	€ 4,000
Premium Membership (please contact us)	€ 12,000

Please choose your preferred payment method:

Credit Card:

Visa or Mastercard only!

Credit Card type:

Account nr:

Exp. date:

Name on Credit Card :

Bank Transfer:

Please provide the following information with your transfer instructions:
“VMA 2006, (Company Name), (Your Name)”

Transfer funds to:

Dexia Banque Internationale Luxembourg - 69, Route d'Esch - L-2953 Luxembourg

Account:

IBAN: LU58 0020 1483 5460 4400 - Name: VMA ASBL - BIC Code: BILLLULL

Check (€ only) :

Please make checks payable to " VMA"

Po nr:

Note:

Conference Participation
The annual membership includes the participation for 1 delegate (company with less than €500K turnover p.a .) or 2 delegates (for larger companies) at our annual meeting.
By default, the contact person mentioned on this form is (one of) the attendee(s) but the actual attendee at the conference can be changed up to the beginning of the conference.


Fields marked with a * are required.

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