Formulário de Inscrição

Personal Information

Title:
Name:		* Name is required
Scientific name (for badge) :
Company/Institution:		* Company/Institution Name is required
Department:
Address:
ZIP Code:		* ZIP Code is required
City:		* City is required
Country:
Telephone (with country code):	+
Fax (with country code):	+
Email:		* Email is required

Registration Fees:

Items:	17-07-2012
EXCURSION TO SINTRA :: 20 July	100

Payment Method:

Please complete the following fields to receive Receipt:

Name on Receipt:	* Name on receipt is Required
Tax file number:	* Tax File Number (VAT) is Required

	Bank transfer	Titular: Sociedade Portuguesa de Química Bank: Millennium BCP (Lisboa, Pt) NIB: 0033 0000 4534 5670 6780 5 IBAN: PT50 0033 0000 4534 5670 6780 5 BID/SWIFT: BCOMPTPL Notes:

	By check	In order to : Sociedade Portuguesa de Química If you know the cheque number and bank, please write that information in the "Notes" box below. Notes:

	Credit card	Not Available.

	Online Payment Services	Please use this option to pay fees with online PayPal services using your PayPal account or directly using your Credit Card, Master Card or American Express.

Form Submission:
The data collected will be used only for the purposes of registration and identification of participants in this event. According to international legislation you are given the right to access, modify and/or delete your data, needing only to send an email to aprauter@fc.ul.pt, stating your intention.

I agree and accept the terms stated above:	Agree