Registration Form

Prof Dr. Dr. Mr. Mrs. Msc.

Participant sponsored by
(please inform the name of company)

Participant:

First Name:

Last Name:

Name for Badge: Sex: F M

Mail Address:

Zip Code: City:

State: Country

Phone: Fax:

E-mail:


Receipt in this name - yes no

Accompanying Person:
(please include age of children)

Adult
Child ( age )

Category

Professionals - U$ 420,00

IUPAC, SBM, SLAM, SBQ, ABQ Members - U$ 380,00

Student - U$ 200,00

Accompanying Person - U$ 140,00

Per day - U$ 150,00


Member of: IUPAC SBM SBQ ABQ SLAM



Meals

Lunch - nº - U$ 16,00 / day

Social programme - nº - U$ 25,00 / Day

Total of Tickets -

Total Value -


Date - / /



Payment Method

Credit Card: VISA MASTERCARD DINERS

Number: Expiration Date:

Confirmation code - 3 numbers in the back side of your credit card:




IF YOU HAVE PREVIOUSLY SENT THIS FORM BY
FAX OR MAIL, PLEASE DO NOT SEND IT ALSO BY E-MAIL.