Registration Form

To register kindly fill-in the following form. Please note that your registration will only be accepted once we have received confirmation of payment in full.

Personal data

Family Name:*
First Name:*
Profession:*
Tax number:*
Address:
Zip Code:*
City:*
Country:*
Tel/Fax:*
Mobile:
Email:*

Registration fee

180 Euro *1
70 Euro - for university students under the age of 25 - please enclose copy of your student card or university certificate. *1
Card or certificate
*1 These amounts do not include meals.

Payment

Cheque Nº Bank Payable to Fundação Bial.
Wire transfer to the Bial Foundation account.
Bank BPI
NIB 002700100153101010005
IBAN PT50002700100153101010005
SWIFT BPI PPTPL
I enclose copy of the wire transfer

Others

Observations:
Name of the Entity and tax number in which the receipt should be issued:
Alternative address for sending the receipt:

Your personal data will only be used for the purposes of registration in the 8th Simposium of the Fundação Bial 'Behind and Beyond the Brain' and for information and/or promotional campaigns relating to the Fundação Bial and/or companies of the Bial Group.
To update, rectify or erase your personal data, please notify us by letter addressed to Fundação Bial, À Av. da Siderurgia Nacional - 4745-457 S. Mamede do Coronado, Portugal, mentioning your name, address and tax identification number.

I hereby consent to the collection and processing of my personal data by Fundação Bial.
* - Required field.

General Information

Limited number of registrations
Simultaneous translation will be assured from English to Portuguese and vice-versa
Symposium's venue: Casa do Médico - Rua Delfim Maia, 405 - 4200-256 Porto
Tel.: +351 225 070 100
Secretariat and general information:
- Fundação BIAL
- À Av. da Siderurgia Nacional - 4745-457 S. Mamede do Coronado - Portugal
- Tel. +351 22 986 6100 - Fax +351 22 986 6199 - fundacao@bial.com

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