SASBE 2012 - PAYMENT FORM
Please complete this form and return it by fax to:
FUNCAMP – The UNICAMP Development Foundation Fax: +55.19.35212868
For more information: Phone: +55.19.35212399 / Email: sasbe2012@funcamp.unicamp.br
FIRST NAME:
INSTITUTION/COMPANY:
ADDRESS:
COUNTRY:
PHONE NUMBER:
E-MAIL:
2-day registration
FULL
PARTICIPANT DETAILS
LAST NAME:
REGISTRATION NUMBER/PAPER ID:
FAX NUMBER:
REGISTRATION FEE
By April 20, 2012
By May 15, 2012
By June 22, 2012
USD 675
USD 750
USD 850
CIB CABA iiSBE Partner members
Group registration
Faculty from developing countries
USD 574
USD 637
USD 723
USD 338
USD 375
USD 425
Students
USD 223
USD 245
USD 282
One-day registration
FULL
REGISTRATION FEE
By April 20, 2012
USD 473
By May 15, 2012
USD 525
By June 22, 2012
USD 595
CIB CABA iiSBE Partner members
Group registration
Faculty from developing countries
USD 402
USD 446
USD 506
USD 237
USD 263
USD 298
Students
USD 156
USD 172
USD 197
PAYMENT DETAILS
BY WIRE TRANSFER:
Correspondent Bank (field 56) : STANDARD CHARTERED BANK - NY - NY - USA
One Madison Avenue, New York - NY 10010
SWIFT Code: SCBLUS33 - ACOUNT: 3544-034644001
Clearing Code : ABA 026002561 ,Chips UID 076399 , BSCHBRSP
Beneficiary Bank (field 57): BANCO SANTANDER S/A. - 033
Rua Ungria, 1400 - São Paulo/SP – Brazil
SWIFT Code: BSCHBRSP
Beneficiary (field 59): Fundação de Desenvolvimento da UNICAMP-FUNCAMP
Ag. 0207 C/C.: 13.046708-4
BY CREDIT CARD (Please, kindly add 7% to cover transaction costs)
Please charge the total of USD
to my credit card:
VISA
MasterCard
American Express
Number _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _ Expiry Date _ _ - _ _ CCV/Security Code _ _ _
Name as it appears on card _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Billing Address of Charge (if different from above) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Authorised Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date: _ _ _ / _ _ _ / _ _ _
CANCELLATION POLICY
Refunds of registration fees are no longer possible.
http://www.fec.unicamp.br/~sasbe2012/