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Registration Form

Name......................................................................................................

Address....................................................................................................

TEL..........................................................................................................
.

Email.......................................................................................................

Type of Accommodation Required

Single Double tripled
I Will/ Will Be attending the Conference
PERAONS SHARING THE ROOM
Type of Accommodation Required
[1] .................................................................................................
[2] ....................................................................................................
SPECIAL NEEDS
.................................................................................................................
................................................................................................................
.................................................................................................................
METHOD OF PAYMENT
CREDIT CARD MASTER VISA
AMEXTEINCE EYPRESS
cc#_____________ DATE OF EXPIIRY___________
MONEY DRAFT: ______________
AMOUNT INCLUDED

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