Registration Number:.................................... Date received:.........../............./................... DELEGATE INFORMATION: (Please Tick all Appropriate) Past District Governor Past AG President Rotarian Rotaractor 1. Last Name 2. First Name 3. Name to show on Badge/Call Name Interactor AG Other (specify)................................................................................................... 4. Rotary/Rotaract/Interact club 5. Classification 6. Spouse/Guest Name (If accompanying) 7. City 8. Country 9. Position in Rotary/Rotaract/Interact 10. Paul Harris Award (Mark as appropriate) 11. E-mail Address Yes Multiple/Major/etc 12. Mobile Phone 13. Alternate Phone ( )- ( )- 18. Please specify special dietary needs 14. Arrival Date 15. Road travel/ Flight details (if applicable) 16. Departure Date 17. Road travel/ Flight details (if applicable) Vegetarian Other (please specify) 19 (a) Accommodation 19 (b) Accommodation required type 19 (c) Hotel (see reverse for details) Check In Date:................................................... Yes No Single Double Triple Check Out Date: ................................................ 20.Calculate your charges SIGNATURE:………………………………………………….…….. DATE:……………………………………………………………… 1 Registration F orm Declaration: I confirm that the above information is true, accurate and complete. I also guarantee to the conference registration committee that I will pay the amount i have indicated above for my registration for the 90th District Conference & Assembly, Rotary District 9211 in the manner shown. 90th District Conference and Assembly Dar es Salaam, Tanzania 13th - 16th May, 2015 Registration No. of Pax Category ROTARIAN SPOUSE/GUEST ROTARACTOR INTERACTOR Number, rate & type of room TOTAL AMOUNT PAYABLE Please calculate the above with relevant date qualification and totals. Please note qualification date will be confirmed on date the form is received at our office. No. of Nights Single: Rate $_________Double: Rate $__________ Triple: Rate $__________ ACCOMODATION SELECTION 100% advance payment required to secure reservation 160 160 90 75 190 230 190 230 90 100 90 100 Total Charges Early Bird Registration Fee (Per Person) Payable by December 31, 2014 2015 Registration Fees (Per Person) Payable by February 28, 2015 2015 Registration Fees (Per Person) Payable March 1st onwards, Credit Card Information: Please provide credit card information for billing ONLY if registration payment mode is through credit card and submit copies of credit card (both sides) with form: Please debit my Credit Card Account - Indicate type of Credit Card (mark as appropriate): VISA MASTER CARD CREDIT CARD NUMBER: ___________________________________ EXPIRY DATE: ______/______ SECURITY NUMBER ______________________________ NAME ON CARD: _________________________________________AMOUNT TO DEBIT: US$ ____________ (Surcharge of upto 3.2% & financial levies will apply to total of item no.xxx) SIGNATURE OF CARD HOLDER: _____________________________ (NB: Registrations sent via email will infer and constitute authority and signature) 21. Credit Card Authorisation & Conditions (only if paying by Credit Card)
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90th District Conference and Assembly Dar es Salaam ... fileBahari Beach Hotel Belinda Jangwani Hotel Giraffe Hotel SeaScape Hotel Please note: a) 50usd is to be deposited at check
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Declaration: I confirm that the above information is true, accurate and complete. I also guarantee to the conference registration committee that I will pay the amount i have indicated above for my registration for the 90th District Conference & Assembly, Rotary District 9211 in the manner shown.
90th District Conference and AssemblyDar es Salaam, Tanzania
13th - 16th May, 2015
Registration No. of PaxCategory
ROTARIAN
SPOUSE/GUEST
ROTARACTOR
INTERACTOR
Number, rate & type of room
TOTAL AMOUNT PAYABLE Please calculate the above with relevant date qualification and totals.Please note qualification date will be confirmed on date the form is received at our office.
ACCOMODATION SELECTION100% advance payment required to secure reservation
160
160
90
75
190 230
190 230
90 100
90 100
Total ChargesEarly Bird Registration Fee
(Per Person) Payable by
December 31, 2014
2015 Registration Fees (Per Person)
Payable by February 28, 2015
2015 Registration Fees (Per Person) Payable March 1st
onwards,
Credit Card Information: Please provide credit card information for billing ONLY if registration payment mode is through credit card and submit copies of credit card (both sides) with form:Please debit my Credit Card Account - Indicate type of Credit Card (mark as appropriate): VISA MASTER CARD
CREDIT CARD NUMBER: ___________________________________ EXPIRY DATE: ______/______ SECURITY NUMBER ______________________________
NAME ON CARD: _________________________________________AMOUNT TO DEBIT: US$ ____________ (Surcharge of upto 3.2% & financial levies will apply to total of item no.xxx)SIGNATURE OF CARD HOLDER: _____________________________ (NB: Registrations sent via email will infer and constitute authority and signature)
21. Credit Card Authorisation & Conditions (only if paying by Credit Card)
24. Registration Guidelinesi. Full payment with the duly completed registration form is required to secure confirmations of both conference space and accommodation (payments may be made by cash, credit cards, wire transfer or bank drafts). Any applicable charge on bank transfer and draft would be payable by the applicant.
ii. Cancellations postmarked by April 15th, 2015 will receive a refund less USD 40.00 processing fee. Cancellations or changes in registration must be in writing and will not be accepted after April 15th, 2015.iii. Cancellation is USD 40.00 - for the registration cost only. Hotel cancellation would be as per the Hotel’s policy.
• It is recommended that hotel bookings be done through the Conference Registration in order to secure discounted rates and to confirm your bookings.
• The Accommodation committee has secured preferred rates at several similar rated Beach Hotels. Room allocation will be effected on first-come-first serve basis (All room rates based on Standard Rooms types)
• Rates quoted below are on Bed and Breakfast basis [Incl. Taxes]. Lunch & dinner served at the designated conference venue.
• 100% Advance payments required to secure and ensure hotel booking reservation (Conditions for cancellation apply).
• 90th DCA Accommodation/Registration Committee(s) to have discretion on room allocation at designated conference hotels – subject to availability
• Transportation coordinated ONLY to-and-from the 90th DCA designated hotels
• For any special needs contact designated accommodation committee [ref No.25]
• Registration will close when capacity of conference is reached.