Personal
Family Name:
First Name:
Date of Birth:
Gender:
Address:
Street:
City:
Zip code:
Telephone Number:
Mobile Number:
Fax:
E-mail:
Occupation:
Information
Rotaract
Club:
District:
Position in club or district:
Health problem, if YES please state it:
Do you have an International Inssurance in case of accidents:
If YES: Which inssurance company:
In case of emergency please contact:
Family Name:
First Name:
Relation:
Home Adress:
Street:
City:
Telephone Number:
Work Number:
Mobile Number:
E-mail:
Traveling Information
Arrival Date:
Num. of flight:
(if already booked)
Departure date:
Num. of flight:
Early Registration (FEB- March): 300 USD, Late Registration (April-May): 340 USD
Interested in two days Pre/Post Conference?