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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