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REGISTRATION
School: Abecedarian of SIDE (ASIDE)
June 27 - July 1, 2016
* MANDATORY FIELDS
IDENTIFICATION*
TITLE*
Ms
Mr
Dr
Professor
Professor Dr
NAME*
Given Name
Family Name
OCCUPATION*
FACULTY/RESEARCHER - WITH GRANT
FACULTY/RESEARCHER - WITHOUT GRANT
POSTDOCTORAL FELLOW
GRADUATE STUDENT (2ND AND 3RD CYCLE)
UNDERGRADUATE STUDENT
ELEMENTARY OR SECONDARY SCHOOL PROFESSOR
INDUSTRIAL RESEARCHER (Industry, Finance, etc.)
UNEMPLOYED
SELF-EMPLOYED
Other
SEX* (for statistical purposes)
Female
Male
AFFILIATION*
Affiliation
Department
Address of Affiliation
City
Postal Code / Zip Code
Please choose a country:
Please choose a state, province or area:
CORRESPONDENCE ADDRESS
Please fill out the following if different from the affiliation.
Correspondence address
Address
City
Postal Code / Zip Code
Please choose a country:
Please choose a state, province or area:
TELEPHONE (with dialing code), EMAIL ADDRESS AND WEB SITE
Email address*
Secondary email address
Office phone*
Home phone
Fax
Cellular Phone
Web Address
Twitter
REGISTRATION FEES*
Registration fees are non-refundable.
Registration Fees $CAN
Please choose
Participant
TOTAL FEES
Total fees $CAN
PAYMENT *
By credit card only.
Credit card information must be valid until the beginning of the workshop.
The following amount will be debited from your credit card.
Payment Card
Name of the credit card holder
Credit card number
Expiry date on credit card MM/YYYY
MISCELLANEOUS INFORMATION
Please write any other information or comment.
