1. INSTITUTION DATA

Name

E-mail

Main Activity

Address

Responsible Officer

Mailing Address

2. REPRESENTATIVES' NAMES

3. FEES FOR FISCAL YEAR 2011 - 2012

Up to 10 representatives: US$ 350
11 to 20 representatives: US$ 450
21 to 30 representatives: US$ 525
31 to 40 representatives: US$ 575
41 to 50 representatives: US$ 600
R$ *

* Total fee in US$ or R$ should be paid with the application. Make checks payable to the order of "Latin American Section of ANS". Payment in US$ can be made by Bank Transfer to account 026-006693 "Latin American Section of ANS" at CHASE Bank New York, NY, USA. Payment in Real should be based on the exchange rate in effect on the date the payment is made.