This form is meant to register for the Annual Meeting of Dutch Statisticians and Probabilists to be held in the Conference Centre 'De Werelt' in Lunteren from 16-18 november 2009. If you have any questions, send an e-mail to Marie-Colette van Lieshout.

Surname and initials: *

First name: *

Affiliation:

Postal Address:

Telephone: *

Type of arrangement: *

the complete arrangement from Monday November 16 before lunch to Wednesday November 18 after lunch (EUR 340 ),

two day arrangement (EUR 240 ),

another arrangement, namely (please specify below):

Another arrangement (specifications):

participation Monday without overnight stay (EUR 100)

participation Tuesday without overnight stay (EUR 100)

participation Wednesday without overnight stay (EUR 100)

Fill in only when chosen "another arrangement, namely" at previous question.

Dietary requirements:

Please indicate any special dietary requirements.

Payment: My total registration fee is: *

Indicate your choice in Euro.

Payment through:

money transfer to Postbank account number: 6273908. Account owner: Bijeenkomst Stochastici, Valkenburgerstraat 131, 1011 MH Amsterdam,

by credit card (non-residents of The Netherlands only please!)

When chosen credit card -: Adress card holder:

-: Card number:

-: Expiry date:

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-: Name card holder:

-: Name credit card company:

-: CVC code (last three digits on the back side of your card):