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