registration form - Generation Europe Foundation

Secretariat Use onlyWorld Assembly of YouthAssemblee Mondiale de la JeunesseAsamblea Mundial de la JuventudDate ReceivedRegistration No.11TH MELAKA INTERNATIONAL YOUTH DIALOGUEJUNE, 27TH - 29TH, 2011, MELAKA, MALAYSIAREGISTRATION FORMPlease complete the form and send to the World Assembly of Youth (WAY)Secretariat by E-mail or Faxbefore the May 31st, 2011. Should you have any enquiries do not hesitate to contact WAY Secretariat on:Tel: +606-2321871/ 2322711 Fax: +606-2327271 e-mail: info@way.org.my or office@way.org.my**PERSONAL INFORMATION:Please type or write clearly in Capital Letters. All fields marked * * and those highlighted in red are required forregistration.Title Mr. Mrs. Ms. Dr. Prof.(Please Specify if others)First NameMiddle NameLast (Family) NameName for BadgePassport NumberDOB {month/day/year}Passport Expiry Date{month/day/year}GenderMaleFemalePermanent AddressCityCountryStateZip CodeMobile Number (country code - area code- Tel no.)E- mailDetails of Next of KinFirst NameMobile Number(country code - area code- Tel no.)Last NameRelation to applicantE- mailSpecial Dietary requirements: (Please tick your choice)None Vegetarian No beef No seafood (Please Specify if others)Special Health Requirements:

ORGANIZATION INFORMATION:Please type or write clearly in Capital Letters. All fields marked * are required for registration.Organization NameType of OrganizationApplicants PositionAddressCity State Zip CodeCountryPhone No.1:(country code - area code- Tel no.)Phone No.2:(country code - area code- Tel no.)Fax :(country code - area code- Tel no.)E- mailWebsite:**TRAVEL INFORMATION:Please fill all fields as required and send confirmed travel details in due time to avoid future inconveniencesTransport Mode : (Please tick your choice)AirRoadRailWaterNeed for visa :(If 'yes' provide us with details to process an application in due time )(Please Specify if others)YESNOAccompanying Person(s)For persons travelling in a group or with other family membersNumber of Accompanying PersonsAre you a group leader?(If 'no' provide us with details of the group leader as requested belowYESNOFirst NameLast (Family) NamePassport NumberGender Male FemaleE- mailMiddle NameName for BadgeDOB{month/day/year}Phone Number(country code - area code- Tel no.)

**Payment DetailsDialogue Fee:All Prices are inclusive of an all round trip from and to Kuala Lumpur International Airport, 4d/5n Accommodation including Meals ,aone day cultural tour and all Dialogue MaterialsGeneral Accommodation:Twin sharing basis at the Hotel. For change of Accommodation kindly liaise with WAY Secretariat via e-mail at least 3 weeks inadvance to avoid any later inconveniences.Additional night including breakfast shall be surcharged an additional amount of USD 50 nettPayment Mode : (Please tick your choice)Cash On Arrival(Kindly note only US Dollars shall be accepted)Others(Please specify)By Transfer kindly remit to :Account Name:Telex Transfer(TT)(Kindly send proof of payment to WAY Secretariat)World Assembly of YouthAccount Number: 5040-1282-8298Bank Name:Branch Name:City:Country:MaybankJalan Munshi AbdullahMelakaMalaysia