Registration Form (Section A)

ampcan ghana logo

Prefix (Title):

Last Name (Surname): *

First Name: *

Mailing Address: *

Company/Organization (if applicable): *

City: *

Postal Code: *

District/State/Province:

Country: *

Fax:

Mobile:

Email: *

Category of Participation: *

Presenter

Non-presenter

Contact Language : *

English

French

Portugese

Telephone: *

Please mark if you have any special dietary requirements:

Vegetarian

Other (Please Specify):

Do you have any medical condition (e.g. allergies) that we should be aware of? Please identify which one(s) or write “none”:

Preferred Accommodation (please refer to Section C)

Hotel:

From Date:

To Date:

Itenerary

Date:

From:

To:

Transfer Required?:

Yes

Airport Pickup Needed?:

Yes

Attachment	Size
Registration Form Sections B and C.pdf	145.41 KB