SPANISH SOCIEDADA OF
INDUSTRIAL DRUGSTORE AND GALÉNICA

Application form of Revenue

Name and surname _______________________________________________________________________________________

Professional activity ____________________________________________________________________________________

Institution / company _____________________________________________________________________________________

Direction _______________________________________________________________________________________________

_________________________________________________________________________________________________________

Phone: _____________________ Fax: _________________ E-mail: _____________________

Bank direct debiting (*)

Account holder:
____________________________________________________________________________________________
Name of the Bank or Box:
____________________________________________________________________________________________
Direction of the Bank:
Calle:____________________________________________________________________________

Nº: ___________ ZIP code: _____________________ Population: _________________________

CODE CHECKING ACCOUNT

Code entity
_______________

Code Office
_______________

A.D.
_______

Number of account
_______________________

Dear Sirs, I request Vds serve to subscribe, up to new order and with charge to micuenta above indicated,
the receipts that there presents to them the SPANISH SOCIETY OF INDUSTRIAL DRUGSTORE AND GALÉNICA.




Signature:

It dates: ___________ of ________________ of ______

To send to:
Juan J. Towers Labandeira
Department of Drugstore and Pharmaceutical technology. Department of pharmaceutics.
South University campus. E-15706 Santiago de Compostela

(*) The associate's quota for the year 2003 is 20,00 €/año


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