Corporate Triple Membership Registration Form

The undersigned organisation wishes to become a Corporate Triple BELTUG member

Company information

(all fields indicated with an * are mandatory)

Organisation *:
Branch *:
Name *:
Nr of employees *:
Street & Nr *:
Zip & City *:
Country *:
Tel *:
Fax *:
E-mail *:
Mobile:
VAT (enter N.A. if not applicable) *:
Your Order Nr to facilitatie payment procedures (enter N.A. if not applicable) *:
Website: www.... :
How I got to know BELTUG (via?) *:

Member 1: Title:
Last & First Name:
Language:
Function:
E-mail:
Member 2: Title:
Last & First Name:
Language:
Function:
E-mail:
Member 3: Title:
Last & First Name:
Language:
Function:
E-mail:

Remarks:

I wish to adhere to BELTUG vzw/asbl. Our membership will be valid until January 1st 2012:

Corporate Triple Membership (pay for two and get a third membership for free) : € 630(ex VAT)

Click "submit" to transmit your affiliation per e-mail or send to:

BELTUG vzw/asbl
Attn Ms A. De Ridder / Knaptandstr 123 at 9100 Sint Niklaas (Fax 03/7664186).
A written confirmation and an invoice will be send to you upon receipt of this form.

Thank you for registering.