registration form
Transcrição
registration form
REGISTRATION FORM Submit to: [email protected]; [email protected] --------------------------------------------------------------------------------------------------------------------------- NAME: --------------------------------------------------------------------------------------------------------------------------- SURNAME: --------------------------------------------------------------------------------------------------------------------------- INSTITUTION: --------------------------------------------------------------------------------------------------------------------------- ADDRESS: ZIP CODE: --------------------------------------------------------------------------------------------------------------------------- CITY: COUNTRY: --------------------------------------------------------------------------------------------------------------------------- TEL: ( ) FAX: ( ) --------------------------------------------------------------------------------------------------------------------------- E-MAIL: --------------------------------------------------------------------------------------------------------------------------- WILL YOU PRESENT A PAPER? YES NO --------------------------------------------------------------------------------------------------------------------------- ARE YOU A LAS-ANS MEMBER? YES NO --------------------------------------------------------------------------------------------------------------------------- ARE YOU A MEMBER OF THE LAS/ANS STUDENT DIVISION? YES NO --------------------------------------------------------------------------------------------------------------------------- Signature LAS/ANS IBQN, Rua do Mercado, 11 – 15º andar - Rio de Janeiro - Brasil - CEP: 20010.120 Tel.: (+55.21) 3078 1610. Fax: (+55.21) 3078 1677. [email protected]
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