APPLICATION FORM

I. ASSOCIATE GENERAL INFORMATION

Name

First Name

Second last name

Gender

MaleFemale

Date of Birth

Place of Birth

ACADEMIC CREDENTIALS

DoctorateMaster’sBachelor’sTechnicianOther

MAILING ADRESS

Street

Outside and Inside number

Subsection

City

State

Zip Code

Contact telephone or mobile

Email Address

Affiliation
AcademiaIndustry

ADDRESS OF INSTITUTION

Street

Outside and Inside number

Subsection

City

State

Zip Code

Telephone of the Institution
(Extension number)

II. PROFESSIONAL DATA

KNOWLEDGE AREA (select your area)

Physics, Mathematics and Earth Sciences
Biology and Chemistry
Medicine and Health
Humanities and Behavioral
Social and Economics
Biotechnology and Farming/Agricultural
Engineering and Industry
Other

III. PAYMENT INFORMATION

Type of procedure
RegistrationRenewal

Type of membership
ActiveHonoraryCooperation

Type of fee as active member: (Select one)
Professional
Postgraduate student
Undergraduate student
Older than 65 years of age
Retired
Industrial professional

Bank reference number or bank transfer reference number

Date of payment

Requires invoice (Notice of need for VAT charge)
YesNo

III.1 Invoice information

Name of company

Tax ID

Address (Street, exterior and interior number, subsection, city, state, zip code)

Email address (for sending invoice)

Telephone (contact for clarification, if needed) or mobile.

IV. ATTACHED DOCUMENTS

Receipt of payment (pdf or jpg)

Copy of current title (diploma) or ID card from the university if applicable. (pdf or jpg)

Copy of proof of current address(pdf or jpg)

V. ADDITIONAL INFORMATION

1.- How did you find out about the SMLS:
(Seleccione una):
Radio
Television
Internet
By means of chats with colleagues
Direct invitation
Through social networks
Friends
Other

2.- In which of the SMLS activities would you be interested
(mark as many as desired):
Courses
Workshops
Symposiums
Webinars
Other