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AIRP 2019 Registration Form
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Family Name
*
Your answer
First Name
*
Your answer
SPRMN Membership number
Your answer
Participant
Full member
Member in-training
Non-Member
Radiographers
General Internship
Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Country
*
Your answer
Hospital
*
Your answer
Department
*
Your answer
Cell Phone
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Fax
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Email
*
Your answer
Participant
Participant - After October 11
SPRMN Full Member, SERAM, SPR, CBR Full Member - €190
SPRMN Member in-training - €160
Non-Members SPRMN - €250
Radiographers - €160
General Internship - €85
Payment
Payment Type
*
Bank Transfer SWIFT Code BBPIPTPL | IBAN 50.0010.0000.48339960.0017.6
Check payable to SPRMN (only Portugal)
Required
Check Number
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Bank Transfer Confirmation
i'll send confirmation by email to
sprmn@sapo.pt
Billing information
Name
Your answer
Billing address
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Tax Identification Number (NIF)
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