Head Office: Koperwerf 28 (7th Floor) 2544 EN The Hague The Netherlands		Post Address: P.O Box 40405 2504 LK The Hague The Netherlands
Contact: Email: info@basug.nl Website: www.basug.nl Phone: +31(0)6-106.444.71 Phone: +31(0)6-516.826.00 Fax : +31(0)70-381.82.04 Chamber of Commerce. nr: 272.758.90		Bank Details: ING Bank The Hague, The Netherlands Account Number: 900.617 IBAN Nr.: NL35INGB0000900617 BIC/SWIFT Code: INGBNL2A
Bangladesh Office: Mr. Muhammed Jahangir Country Coordinator Hall-Mars 6/7 Maghbazar Outer Circle Road (6th Floor) Dhaka, Bangladesh Phone: +880-02-933.46.56 Phone: +880-1711.53.888.9		UK Chapter: Country Coordinator Mr. Ansar Ahmed Ullah Phone: +44-795.689.06.89
Belgium Chapter: Country Coordinator Dr. Ahmed Ziauddin Phone: +32-476.981.350

SALUTATION	Mr. Ms. Mrs. Dr. Prof.
FIRST NAME
LAST NAME
ADDRESS
CITY
POSTCODE
PHONE
FAX
EMAIL ADDRESS
SUBJECT
COMMENTS
	= Required