Registration Form - ECSA 54
Transcrição
Registration Form - ECSA 54
Registration Form Personal Information Name Address City Zip code Country Email Phone Fax VAT Number (EU citizen only) Invoice Information (if different from Personal Information) Name Address City Zip code Country VAT Number (EU citizen only) Conference Fee A copy of a document proving member or student status (e.g. student card) must be sent by e-mail to [email protected] or by fax to + 351 217500207 Conference Dinner Payment & Conditions By International Bank Transfer Account holder: Account number: IBAN: SWIFT CODE: Bank name: Branch address: Reference: Fundação da Faculdade de Ciências da Universidade de Lisboa 0840 1919 0000 PT50 0007 0084 0001 9190 0001 2 BESCPTPL BES - Banco Espírito Santo, S.A. BES-FCUL, Edifício C7, Campo Grande, 1749-016 Lisboa Name, ECSA 54 By National Bank Transfer Nome do Banco: Nº de Conta: NIB: Descrição: BES - Banco Espírito Santo, S.A. 0840 1919 0000 0007 0084 00019190000 12 Nome, ECSA 54 Amount due (Euros) All Payments in Euros. Bank transfer expenses must be supported by the participant. ECSA54 and your name should be clearly mentioned in the form of the bank transfer. Payments with missing information may not be considered. Transfer confirmation must be sent by e-mail to [email protected] or fax +351 21 750 0207 By Credit Card (Visa or Mastercard only) Payment by Credit Card (An additional 3 % fee will be charged on all credit card payments) I authorize (Euros) to be charged on my credit card. Card Holder's Name Credit Card Number CVV (3 rightmost digits on the back of the card) Expiration Date Country where credit card was issued Signature: Please send the completed registration form to [email protected] or fax +351 21 750 0207
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