MEMBERSHIP APPLICATION



|Registration Form |

|AZORES DEG/CRUSUS SUMMER COURSE 2011 |

|Applicant Information |

|Family name: |Gender: ( ) male ( ) female |

|First name: |Birth date [MM/DD/YYYY]: |

|Place of birth (city): |Place of birth (country): |Citizenship: |

|Permanent address (street name and number): |

|City: |State: |Country: |Zip code: |

|Home phone number (including country and area code): |

|Mobile phone number (including country and area code): |E-mail: |

|professional Information (if applicable) |

|Current employer: |

|Category of employer: ( ) private company ( ) public organization ( ) NGO ( ) university/school |

|Employer address: |Sector: |

|Phone: |E-mail: |Fax (if applicable): |

|City: |State: |Country: |

|Postal code: |Position: |Department: |

|education information |

|Current academic degree: |

|Are you currently studying for another academic degree? ( ) No ( ) Yes (specify): |

|Current or last Institution: |City: |Country: |

|Website of the institution: |

|How did you find out about the azores summer course |

|( ) Friends |

|( ) School (please, specify): |

|( ) Facebook |

|( ) Internet search engine |

|( ) Website (please, specify): |

|( ) Other source: please, specify): |

|REGISTRATION FEE TO BE PAID |

|( ) 400 EUR (earlier registration until 13th May) |

|( ) 450 EUR (late registration after 13th May) |

|( ) 300 EUR (student of the University of Azores) |

|( ) 300 EUR (student of the University of Pardubice) |

|( ) 300 EUR (CRUSUS associate member) |

|RECALL YOUR GROUP DISCOUNT (IF APPLICABLE) |

|Full name of colleague 1: |Full name of colleague 2: |

|Note: in order to receive group discount, the registration of the colleagues mentioned above have to be also confirmed. A joint payment has|

|to be done through one only invoice. |

|Fill out this registration form and submit us through the e-mail: azores2011@. You will be soon notified about the receipt of |

|this document. After verification of the total amount to be paid for your registration and a confirmation from your side, you will be |

|kindly asked to make the payment through one of the chosen payment methods. You will receive a copy of this registration form with our |

|signature and an invoice for your registration fee. |

For additional information about the registration process or course programme, contact:

José Manuel Rosa Nunes

Departmental Coordinator for External Relations

Department of Economics and Management (DEG)

University of Azores - Portugal

Telephone: + 351 296 650 092

email: rnunes@uac.pt

Ticiano Costa Jordão

Sustainability Crusade Observatory (CRUSUS)

Phone: +420 739 064 441

E-mail: tcjordao@

tcjordao@

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