WSSCC Global Forum on Sanitation and Hygiene - Registration Form

Title: Prof. Dr. Eng. Mr. Ms. First name(s):_____________________________________________ Last name: __________________________________________Affiliation: _______________________________________________ Nationality: _________________________________________Address: ___________________________________________________________________________________________________City: ___________________ State: _________________Country: ________________________ Postal / Zip Code: __________________ Phone : _________________________________ Mobile: ____________________________ Fax: _____________________________ Email: _____________________________________________________________________________________________________Personal DetailsNon-local ParticipantsProfile QuestionnaireAccompanying Person - Spouse / Partner Title First name(s) Last name(s)1. Registration fees Regular Registration Fee Onsite Until 30/09/2011 from 01/10/2011 Participant, all inclusive (accomodation, meals, airport transfer, and conference fees) $ 1, 250 $ 1, 375 Student, all inclusive (25% discount) $ 950 $ 1, 045 Journalist (accommodation, meals and airport transfers) $ 950 $ 1, 045 Journalist (Conference access only, no accommodation, no meals, no airport transfers, conference fees waived) Accompanying person (accommodation, meals, airport transfers, no access to sessions) $ 650 $ 715 • Non-local Participant registration fee: Fee includes the following services: airport transfers, accommodation for the entire conference, all meals, conference fee and materials, hotel amenities (swimming pool, gymnasium, etc.), business services, urban field visit and social events. *Participant fee does not include travel, visa costs or rural field visit.• Non-local Student registration fee (discount): Fee includes the following services: airport transfers, accommodation for the entire conference, all meals, conference fee and materials, hotel amenities (swimming pool, gymnasium, etc.), business services, urban field visit and social events. *Participant fee does not include travel, visa costs or rural field visit.Registration Form YesJournalist Other (Please Specify): ______________________________ .(If Yes, the visa application fee will be paid by myself)Tick this box if your accompanying person will attend the Welcome Reception on 9 October 2011 from 20.00 to 22.00 hrs(If Yes, airfare will be paid by myself)Please Specify : ______________________________ .NoYes NoYes No1. Are you a member of WSSCC? 2. Which field are you working in3. Do you have any specific dietary requirements?4. Please tick your answer below NGO Private Sector Academia Government United Nations Independent Free Free 1/4I would like to request a visa letter5. I would like to request airline bookingGender: Male FemaleTitle: Prof. Dr. Eng. Mr. Ms. First name(s):_____________________________________________ Last name: __________________________________________Affiliation: _______________________________________________ Nationality: _________________________________________Address: ___________________________________________________________________________________________________City: ___________________ State: _________________Country: ________________________ Postal / Zip Code: __________________ Phone : _________________________________ Mobile: ____________________________ Fax: _____________________________ Email: _____________________________________________________________________________________________________Personal DetailsNon-local ParticipantsProfile QuestionnaireAccompanying Person - Spouse / Partner Title First name(s) Last name(s)1. Registration fees Regular Registration Fee Onsite Until 30/09/2011 from 01/10/2011 Participant, all inclusive (accomodation, meals, airport transfer, and conference fees) $ 1, 250 $ 1, 375 Student, all inclusive (25% discount) $ 950 $ 1, 045 Journalist (accommodation, meals and airport transfers) $ 950 $ 1, 045 Journalist (Conference access only, no accommodation, no meals, no airport transfers, conference fees waived) Accompanying person (accommodation, meals, airport transfers, no access to sessions) $ 650 $ 715 • Non-local Participant registration fee: Fee includes the following services: airport transfers, accommodation for the entire conference, all meals, conference fee and materials, hotel amenities (swimming pool, gymnasium, etc.), business services, urban field visit and social events. *Participant fee does not include travel, visa costs or rural field visit.• Non-local Student registration fee (discount): Fee includes the following services: airport transfers, accommodation for the entire conference, all meals, conference fee and materials, hotel amenities (swimming pool, gymnasium, etc.), business services, urban field visit and social events. *Participant fee does not include travel, visa costs or rural field visit.Registration Form YesJournalist Other (Please Specify): ______________________________ .(If Yes, the visa application fee will be paid by myself)Tick this box if your accompanying person will attend the Welcome Reception on 9 October 2011 from 20.00 to 22.00 hrs(If Yes, airfare will be paid by myself)Please Specify : ______________________________ .NoYes NoYes No1. Are you a member of WSSCC? 2. Which field are you working in3. Do you have any specific dietary requirements?4. Please tick your answer below NGO Private Sector Academia Government United Nations Independent Free Free 1/4I would like to request a visa letter5. I would like to request airline bookingGender: Male Female• Accompanying person registration fee: Fee includes the following services: airport transfers, accommodation for the entire conference, all meals, hotel amenities (swimming pool, gymnasium, etc.), urban field visit and social events. *Participant fee does not include travel, visa costs, conference access, or rural field visit.Social Events Local Participants Registration feesLocal Participant (meals and conference fees only, no accommodation) Local Student (meals and conference fees only, no accommodation) (25% discount) Local Journalist (conference access only, no accommodation, no meals,conference fees waived) Local Participant Daily fee ( lunch, conference access, no accomodation)Regular Registration fees Onsite30/09/2011 from 01/10/2011Additional Activities/Trainings• Non-local journalist registration fee (discount): Fee includes the following services: airport transfers, accommodation for the entire conference, all meals, conference materials, hotel amenities (swimming pool, gymnasium, etc.), business services, urban field visit and social events. *Participant fee does not include travel, visa costs or rural field visit.• Non-local journalist registration fee (Conference Access only): Fee includes the following services: conference access and materials. *Participant fee does not include travel, accommodation, meals, visa costs or rural field visit.Total Registration Fees _________________US$Total Registration Fees _________________US$Total Welcome Reception Ticket(s) $ 450$ 350Free Free$ 495$ 385$ 150 $ 165• Local Participant registration fee:• Local Student registration fee (discount):• Local journalist registration fee (Conference Access only):Please choose ONE of these four options for Tuesday 11 October: • Local Participant Daily fee:Fee includes the following services: all meals, conference fee and materials, business services, urban field visit and social events.Fee includes the following services: all meals, conference fee and materials, business services, urban field visit and social events.Fee includes the following services: conference access and materials.Fee includes the following services: lunch, conference fee and materials, business services, urban field visit and social events (if applicable)*Participant fee does not include travel, accomodation, dinner, or rural field visit. *Participant fee does not include travel costs, accommodation or rural field visit. *Participant fee does not include travel costs, accommodation or rural field visit.*Participant fee does not include travel costs, accommodation or rural field visit.Venue: Renaissance Mumbai Convention Centre - Mumbai, India I would like to attend the Urban Field Visit in Downtown Mumbai on (no additional cost to participants) I plan to attend the Welcome Reception on 9 October 2011 from 20.00 to 22.00 hrs. The welcome reception is the first social opportunity during the Global Forum to network and mingle, while experiencing the flavour of India. I would like to attend the Rural Field Visit in Maharashtra on the 14-16 October ( $200 per person, which includes meals, overnight accommodation and transport)2/4 I would like to participate in the Communications for Behavior Change (COMBI) training I would like to participate in the CLTS 101: Introduction to CLTS training I will not be participating in any of these activities• Please note that accreditation can only be issued on the basis of a copy of your National or International Press Card, or an official confirmation on The Global Forum on Sanitation and Hygiene welcomes representatives of the media - press, photo, radio, television and film – to cover the Forum. your employment with a company in the media sector. In certain cases, a published article could serve as proof. Please include copies of the relevant materials when submitting your registration. • Please note that accreditation can only be issued on the basis of a copy of your National or International Press Card, or an official confirmation on The Global Forum on Sanitation and Hygiene welcomes representatives of the media - press, photo, radio, television and film – to cover the Forum. your employment with a company in the media sector. In certain cases, a published article could serve as proof. Please include copies of the relevant materials when submitting your registration. 3/4Payment ModeIndividual & Group Cancellation PolicyTerms & ConditionsSub - TotalsBeneficiary MCI Management India Pvt. Ltd.Address IFCS Code Payment can be made by either of the following modes: Bank Transfer * Please indicate your name and WSSCC 2011 against remmitance reference enabling our bank to accurately locate your payment Please choose ONE of these Post-Conference trainings (trainings will take place on Friday 14 October, 17202320000073Bank Account SCO 321, Sector - 29, Gurgaon - 122002HDFC0001720Cancellation 2 months prior to event: 50% refund.Cancellation 1 month prior to event: 25% refund. If the payment is made after the deadline of the regular registration fee, an onsite fee will be applicable and invoiced If the payment is made 10 days before the forum, a proof of payment or a letter of guarantee will be required Name changes can be made at anytime until 2nd October 2011. After this date an administrative fee of USD 20.00 per name change is applicable. If you cannot attend the forum, we are happy to accept a substitute colleague until the 18th September 2011. If you have to cancel entirely, we regret that no refunds can be made after this date. Cancellation 3 weeks to date of conference: no refund.Sub Total Registrations USD GRAND TOTAL USD I would like to participate in the Sanitation Marketing training I would like to participate in the Equitable Service Delivery training I would like to participate in the Monitoring Behaviour Change training I will not be participating in the post-conference trainingsthe day after the closing plenary): Airport Transfers & Flight DetailsI have made my own flight arrangement. The details are below. I would like MCI to research flight itineraries based on the information below. Arrival Departure Flight Details Date Airline/ Carrier Flight No. Flight TIme Total No. of Person(s)NOTE: Please provide your travel information below so that MCI may arrange transport for you to and from the hotel. If you would like MCI to make flight arrangements for you, please tick the appropriate box and indicate your preferred travel days. Before booking any tickets on your behalf MCI will verify all travel dates and costs with you directly.Total Fee for Rural Field Visit _________________US$ Please fax or email a copy of both sides of the credit card including your passport copy to: MCI Management India Pvt. Ltd., 406 Millennuim Plaza Tower A , Sector 27, Gurgaon 122 002. India. Fax: +91 (0) 124 41 08 917Email: wsscc2011@mci-group.com Contact DetailsOnly Visa and MasterCard are accepted. I hereby authorize MCI Management India Pvt. Ltd. to debit my credit card as followsCredit Card Payment Authorization Visa MasterCard Credit card number: Expiry Date:Credit Validation code (3 digits on reverse of your credit card): Grand Total US $:/Signature: ________________________________________ Date: ______________________________________________________Credit card holder’s name (please print): _______________________________________________________________________________MCI Management India Pvt. Ltd. (conference Secretariat)Address: 406 Millennuim Plaza Tower A , Sector 27, Gurgaon 122 002. India. Tel: +91 (0) 124 49 74 160Fax: +91 (0) 124 41 08 917Email: wsscc2011@mci-group.comWebsite: www.wsscc.global-forum.org Payment is settled in USD according to the exchange rate of the day when the above credit card is debited by MCI.Further InformationFor further information / queries on this booking form, registration or any other aspect related with WSSCC Global Forum on Sanitation and Hygiene 2011,please contact the conference organisers, MCI Management India Pvt. Ltd.4/43/4Payment ModeIndividual & Group Cancellation PolicyTerms & ConditionsSub - TotalsBeneficiary MCI Management India Pvt. Ltd.Address IFCS Code Payment can be made by either of the following modes: Bank Transfer * Please indicate your name and WSSCC 2011 against remmitance reference enabling our bank to accurately locate your payment Please choose ONE of these Post-Conference trainings (trainings will take place on Friday 14 October, 17202320000073Bank Account SCO 321, Sector - 29, Gurgaon - 122002HDFC0001720Cancellation 2 months prior to event: 50% refund.Cancellation 1 month prior to event: 25% refund. If the payment is made after the deadline of the regular registration fee, an onsite fee will be applicable and invoiced If the payment is made 10 days before the forum, a proof of payment or a letter of guarantee will be required Name changes can be made at anytime until 2nd October 2011. After this date an administrative fee of USD 20.00 per name change is applicable. If you cannot attend the forum, we are happy to accept a substitute colleague until the 18th September 2011. If you have to cancel entirely, we regret that no refunds can be made after this date. Cancellation 3 weeks to date of conference: no refund.Sub Total Registrations USD GRAND TOTAL USD I would like to participate in the Sanitation Marketing training I would like to participate in the Equitable Service Delivery training I would like to participate in the Monitoring Behaviour Change training I will not be participating in the post-conference trainingsthe day after the closing plenary): Airport Transfers & Flight DetailsI have made my own flight arrangement. The details are below. I would like MCI to research flight itineraries based on the information below. Arrival Departure Flight Details Date Airline/ Carrier Flight No. Flight TIme Total No. of Person(s)NOTE: Please provide your travel information below so that MCI may arrange transport for you to and from the hotel. If you would like MCI to make flight arrangements for you, please tick the appropriate box and indicate your preferred travel days. Before booking any tickets on your behalf MCI will verify all travel dates and costs with you directly.Total Fee for Rural Field Visit _________________US$ Please fax or email a copy of both sides of the credit card including your passport copy to: MCI Management India Pvt. Ltd., 406 Millennuim Plaza Tower A , Sector 27, Gurgaon 122 002. India. Fax: +91 (0) 124 41 08 917Email: wsscc2011@mci-group.com Contact DetailsOnly Visa and MasterCard are accepted. I hereby authorize MCI Management India Pvt. Ltd. to debit my credit card as followsCredit Card Payment Authorization Visa MasterCard Credit card number: Expiry Date:Credit Validation code (3 digits on reverse of your credit card): Grand Total US $:/Signature: ________________________________________ Date: ______________________________________________________Credit card holder’s name (please print): _______________________________________________________________________________MCI Management India Pvt. Ltd. (conference Secretariat)Address: 406 Millennuim Plaza Tower A , Sector 27, Gurgaon 122 002. India. Tel: +91 (0) 124 49 74 160Fax: +91 (0) 124 41 08 917Email: wsscc2011@mci-group.comWebsite: www.wsscc.global-forum.org Payment is settled in USD according to the exchange rate of the day when the above credit card is debited by MCI.Further InformationFor further information / queries on this booking form, registration or any other aspect related with WSSCC Global Forum on Sanitation and Hygiene 2011,please contact the conference organisers, MCI Management India Pvt. Ltd.4/4