Name______________________________________________________
Mailing address___________________________________________
___________________________________________
___________________________________________
___________________________________________
Telephone number_______________Fax number_________________
E-mail address____________________________________________
Number of copies_______ x 3 000$00 = ____________ $00 PTE
Mailing charge if ouside Portugal = ____________ $00 PTE
(1 500$00 the first copy,
750$00 for each further copy)
Total amount due = ____________ $00 PTE
(Portuguese Escudos)
Charge my Credit Card(X)___ )
Credit card type_________________Number___________________
Expiration date__________________Signature________________
Bank transfer(X)__ to:
LIP
account number: 001705200000577116141
at Banco Portugues do Atlantico
Balcao (counter): Campo Pequeno
Lisbon
Portugal
To certify your payement, please send also a copy of your bank transfer slip.