Entry Form	(PLEASE FILL OUT IN BLOCK LETTERS)

NAME : …..................…..................…..................…..................…..................…..................

I register as * individual / * member of / * officially representing (* strike out what does not apply)

ASSOCIATION / INSTITUTE / COMPANY :

ADDRESS :

POSTAL/ZIP CODE: TOWN: COUNTRY:

PHONE:	FAX:

E-MAIL:

WEBSITE:

...................................................................................................................................................................

r I will take part in 'Industrial Heritage 2013 in Neuchâtel and La Chaux-de-Fonds (Switzerland)

I transfer the 'solidarity fee' of

65 euro p.p. (non-members) / 50 euro p.p. (members of E-FAITH, max. two representatives per member association)
into the E-FAITH bank account at the KBC-bank (Belgium)
account n 462-7331701-51, IBAN BE75 4627 3317 0151, BIC KREDBEBB

r I will take part in the guided visit on Sunday October 27th

r I will present a paper dealing with the theme of the meeting (endangered industrial and technical heritage):

(title:)

..

I have read the conditions and I understand that the maximum speaking time allowed is 15 minutes and I add hereby a short presentation of my speech (max. 10 lines) in the language of the reading. After the meeting I will also deliver to the secretariat, as soon as possible and not later than December 31st, a summary of my speech (max. 1500 words) in the language of the reading, AND max. 200 words in another language (to be published on the E-FAITH website).

r I would like to give a short (max. 7 minutes) presentation of the aims and activities of my association:

(title:)

..

I have read the conditions and I understand that the maximum speaking time in this case allowed is 7 minutes and I add hereby a short text (max. 10 lines) in the language of the reading.

r I would like to formulate the following proposal for the European Industrial and technical Heritage Year 2015 (during the afternoon workshop):

..
I add hereby a summary(max. 10 lines) in the language of the reading.

r I would like to support E-FAITH by becoming member of the federation.

Full members (associations and NGOs, with a right to vote at the general Assembly – see conditions to affiliate on E-FAITH's website) pay 50 euros

Supporting members pay 30 euro for individuals; 50 euro for non-profit non governmental organisa
tions or 150 euro for private enterprises and companies, for public authorities and governmental institutions

Place and date :

Name, Stamp and signature :

Please return this entry form as soon as possible to the address below:

E-FAITH / Industrial Heritage 2013

Vredelaan 72, B-8500 Kortrijk (Flanders - Belgium) : fax +32.56.255173 2013@e-faith.org