*** E R S A D S  ' 9 9 ***

**REGISTRATION FORM**

Please fill in, and email/mail/fax to address above, together with payment:

Mr/Mrs/Ms:. ......................................................

First Name:.......................................................

Last Name:........................................................

Affiliation:......................................................

Address:..........................................................

..................................................................

E-mail:...........................................................

Phone:(+.....)-.................Fax: (+.....)-....................

Seminar fee                                Before Mar. 15          After Mar. 15
[ ] Single room                             180 000 PTE             225 000 PTE
[ ] Double room                             150 000 PTE             205 000 PTE
[ ] Student (double rooms only)             125 000 PTE             180 000 PTE

[ ] I will be sharing the room with:

Mr/Mrs/Ms:............................Affiliation:.................

Payment in Portuguese Escudos (PTE) only. One EURO approx. 200 PTE


PAYMENT

Total amount:...............PTE (Portuguese Escudo)

[ ] Bank cheque enclosed

[ ] Bank transfer
                NB: Cheque payable to Fundação da Faculdade de Ciências da UL
                NB: Transfer addressed to Fundação da Faculdade de Ciências da UL
                    Account nr. 001502200080000770187
                    Bank Address: Banco Pinto e Sotto Mayor,
                    Campo Grande, 1700 Lisboa, PORTUGAL
                    ** PLEASE SEND A COPY OF THE TRANSFER WITH THIS FORM **

[ ] American Express    [ ] Diners Club     [ ] Eurocard
[ ] Visa [ ] Mastercard
I authorise the amount of _________ PTE  to be charged to my credit card.

Credit Card Number:...............................Exp. date:...........

Card holder name:......................................................

Date:............Signature:............................................