26th Symposium on INFORMATION THEORY in the BENELUX
            May 19th-May 20th, 2005, ULB, Brussels, Belgium

------------------------------------------------------------------------------
-                             Registration form                              -
------------------------------------------------------------------------------

First Name:

Last Name:

Affiliation:

Address:

Postal code:

City:

Country:

Phone:

Fax:

Email:

Conference fee:  150 EUR


The above information must be sent by email (to it05@ulb.ac.be) 
or by fax (+32 2 650 56 09) and the conference fee has to be paid, 
before the 21th of April, thanks to an international transfer to:

 Account holder: Université Libre de Bruxelles
 Account number: 210-0429400-33
 Bank name: Fortis Bank
 Bank Address:  Agence Solbosch, Avenue Paul Heger 22, 1050 Brussels, Belgium
 Swift code or BIC code: GEBABEBB
 IBAN: BE79 2100 4294 0033
 Communication (must be correct): BeneluxIT-FL052-4-R00000