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CLIMATE CHANGE AND POPULATION CONFERENCE ON AFRICA

01 – 04, July 2012, University of Ghana, Legon Accra, GHANA

CONFERENCE / PARTICIPANT REGISTRATIONSEND COMPLETED FORM to Email:

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Personal INFORMATION

Family Name / First Name / Middle Initial: / Country of Citizenship:
Organization / Affiliation:
Address: / Country: Sex: Male Female
Title & Position: / Telephone / Mobile:
Fax: / Email: / Website:
MEETING INFORMATION
Are You Presenting a Paper? Yes No / Are You Part of Any Pre-ConferenceSession? Yes No
[Please tick all that apply to your expertise]
Biophysical Scientist / Social Scientist / Policy Interdisciplinary Other:
[Type of Profession]
Researcher / Practitioner / Teaching / Academia Other:
For Resident Ghanaian Students Only
Student (Proof required, E.g. Student ID Card / Admission Letter) / Chairing A Session – Professionals Only:
Would you chair a session? Yes No
Are You a Member of a Professional Society? Yes No ;
If Yes, Which?
Meeting Name Tag
How do you want your Nameto Appear on the Name Tag? [No Titles]
Institutional Affiliation on the Meeting Name Tag?
Country Identification / Affiliation
Anything That You Want Us To Know (Comment):
PAYMENT INFORMATION / DETAILS
Payment Category / Currency / Regular
April 01 – May 31 / Late
June 01 - 15
1. Resident Outside Ghana / US$ / 260.00 / 300.00
2. Resident in Ghana / GH¢ / 260.00 / 300.00
3. Resident Ghanaian Students Only / GH¢ / 120.00 / 120.00
Further Registration Information:
Carbon Offset Fee [OPTIONAL]= $20.00 or GH¢20.00 Yes No . If Yes, Add to Registration and Total Below
AMOUNT PAID [Select Currency and indicate Amount] In US$ In GH¢
Are You Paying Yourself? Yes No . If No, Name of Person Paying
Means of Payment [check which is applicable]:
Bank / Wire Transfer ; Western Union / Money Gram / OtherProof required to
Wire / Bank Transfer - Proof of Payment:
  1. Kindly scan (pdf preferred) and send Payment Receipt / Slip to
  2. Indicate name of Participant on Payment Slip if NOT participant paying herself or himself and Send to Email
  3. Mark Payment Slip “Conference” before sending

PLEASE RETURN FORM ONLY AFTER PAYMENT HAS BEEN EFFECTED TO
For Official Use Only
Website: Email: