A non-refundable deposit of $650.00 required to process registration is due on February 15, 2005.
Name Date of Birth
Place of Birth Passport #
Occupation Email Address
Work Address
Home Address
Home Telephone Work Telephone
Mobile Telephone Immediate relative
Contact information of Immediate relative
I am a smoker I am non-smoker I have disabilities and require following special needs
I/We hereby authorize you to register me/us for the above conference. I/We require the following services:
The price for conference participation is $650.00 per person.
The cost for hiring an exhibition booth is $550.00.
Final payment is due February 15, 2005.
I/We enclose my/our certified check money order authorize Africa First, LLC to charge the sum
of $ against my/our visa master credit card number
Expiry date on card Name on Card
Signature Date
This credit card information may be sent to an unsecured site and may be visible to others.
IMPORTANT NOTICE: Before submitting this form, all applicants must read and accept the terms and conditions set forth at the main Africa First web page, in order to participate in this and other related programs.
IMPORTANT NOTICE
U.S. residents without credit cards can pay with certified checks and money orders.
Participants outside of the U.S. without credit cards can pay via bank transfer or international money orders.
The appropriate application form will be furnished electronically or by mail on request for this process.
