Click here if you prefer a printed form. (Portuguese only)

Name:

Age:

Sex: M F

Address:



Postcode:



Town:



State:



e-mail



CIC (Tax number)

Identity Card nº

Issued by

Nationality



Most important academic title / Institution



Institution where you work/study and your function




Participation in the 5th MHM

I wish to participate as an auditor

I wish to submit a thematic study



wish to submit a statement of research




Means of Payment

Send cheque for R$40,00 made out to "Pró-Música Cultural Centre" to the following address:

5º Encontro de Musicologia Histórica
Pró-Música Cultural Centre
Av. Rio Branco, 2329 - Centro
36010-011 - Juiz de Fora - MG

Cheque nº

Branch

Bank