MIPAA Lisbon 2017

Personal Information

* Mandatory fields

Title *

First Name *

Last Name *

Institution *

Address

Postal Code

City

Country *

Phone *

Fax

Email *

Health

The information provided is confidential

Identity Document

Arrival/Departure

Arrival

Departure

Username & Password

Password *

Please create a Username and a Password so you can later add new services

Position

Date of Birth
(dd/mm/yyyy) *

Country of Birth *

Representing Country *

Nationality *

Participating as *

Preferred Language *

Blood Type

Health Concerns

Accessibility Needs

Dietary Needs

Type *

Number (ID or Passport) *

Country of Issue *

Expiry Date
(dd/mm/yyyy) *

Do You Need
a Visa? *

Arrival Date
(dd/mm/yyyy) *

Arrival Airport *

Departure Date
(dd/mm/yyyy) *

Departure Airport

Dinners

20th September Dinner Participation *

21st September Dinner Participation *

Payment

Value

Bank transfer

The bank transfer must be made to the account number mentioned below, free of charge to the recipient:

Bank Address: Millennium BCP
Av. Prof. Dr. Cavaco Silva (Tagus Park)
Edifício 2/Piso 0 b
2477-002 Porto Salvo, Portugal

Payee: VIAGENS ABREU, SA
VAT Number: 500297177

Bank Account: 0000000000231320
IBAN: PT50 0033 0000 00000231320 83
NIB: 0033 0000 00000231320 83
Swift: BCOMPTPL

Credit Card

Card Number

Name

Expires on

Code (the last 3 digits on the back of the credit card)

Credit Card Issued in USA / Canada / Australia
(You will be contacted with the details for the payment within the next 48h)

Comments

REGISTRATION FORM

Online Registration Closed.