Registration Form

REGISTRATION FORM

Name : ___________________________

Representing: ___________________________

Designation: ___________________________

POSTAL ADDRESS
PHYSICAL ADDRESS
EMAIL ADDRESS
URL
TELEPHONE
FAX
MOBILE
PROVINCE

NB: As indicated on the Dialogue Invitation letter, the dialogue will culminate in a workplan and sector position paper. Therefore delegates are requested that they ensure they are authorized to sign such documents on behalf of their organizations.

Please indicate which area of the sector your organization operates in:

FAITH BASED
LEGAL
HIV/AIDS
ADVOCACY
ACADEMIC
REPRODUCTIVE HEALTH
GOVERNMENT
LOCAL NGO
GOVERNMENT
DONOR
POLITICAL
OTHER
INTERNATIONAL NGO
MEDIA

Logistics!


PLEASE CIRCLE

Will you require accommodation on the night of the 10th September 2008? (Delegates will be accommodated at the Holiday Inn Garden Court ORT International)

YES NO

Would you prefer a smoking or non smoking room?

SMOKING NON SMOKING

Do you have any dietary Preferences?

HALAAL VEGETARIAN OTHER

Will you require parking?

YES NO

If yes please provide your vehicle registration number



In case of emergency please provide us with a number to call

Name ______________________________

Tel: ________________________________


If you are from outside Johannesburg, please provide us with the following details to assist us in coordinating your transport to the Dialogues.

Please give us the name of your nearest Airport:

_______________________________________


Please provide your ID or Passport Number:___________________________________________