DIMVA Registration Form
Participant information	
First name		
Last name		
Nationality		
GI or Student identification(*)		
Company / organization		
Position / title		
Street address		
Zip code		
City		
Country		
Telephone		
Fax		
E-mail		
Mobile		
Please provide at least one  contact information so that we can contact you in case of issues with your registration

Registration fee	
	Before june 10th	After june 10th	Number	Amount	
GI Member (1)	250 €	300 €			
Participant	300 €	350 €			
Student (1)	100 €	150 €			
Additional social event ticket (2)	85 €	100 €			
Total	€ (euros)	
(1)If requesting GI or student registration, please include your GI membership number or student ID
(2) Please note that we have space constraints for the social event and that requests for additional social event tickets after june 15th may be rejected

Payment
Payment method:	Credit card				Bank transfer 	
Bank Transfer
Bank account number: 1901538908
Bank name: Sparkasse KölnBonn, Hahnenstr. 57, D-50667 Köln
Account Holder: Gesellschaft fuer Informatik e.V.
IBAN: DE29 3705 0198 1901 5389 08
Swift BIC: COLSDE33
If using bank transfer, please ensure that the amount transferred is in Euros and free of bank charges.
Credit Card
Credit card: Visa 				Mastercard	 			Diners 
Card number : ___________________________________________________________
Expiration date:   Month ____________________	Year: _____________________
Cardholder’s name : _____________________________________________________________
Signature :______________________________________________________________________
Invoice to
Company name and address:	_______________________________________________________
				_______________________________________________________
Company registration #:	_______________________________________________________
VAT registration :		_______________________________________________________