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4TH INTERNATIONAL CONFERENCE & EXHIBITION ON TRADITIONAL MEDICINE

"TRADITIONAL HEALING & HIV/AIDS" - SENEGAL, APRIL 11-13, 2005

 

REGISTRATION FORM 2

PARTICIPANTS FROM AFRICA AND THIRD WORLD COUNTRIES

A non-refundable deposit of $300.00 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 enclose a non-refundable deposit in the amount of $300.00 and authorize you to register

me/us for the above conference. I/We require the following services:

 

The price for 3 nights hotel accommodation with breakfast and ground transportation on room sharing

     basis is $550.00 per person.

 

The price for 3 nights hotel accommodation with breakfast and ground transportation on single room is

     $800.00 per person.

Conference participation only. Price is $300.00 per person

Exhibition booth hiring. Price is $250.00 a booth.

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

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.