NGO Forum on Ageing 5-9 April 2002

Please to send the registration form to :
SIASA VIAJES S.A.
Paseo de La Habana, 134
28036 Madrid, España
Tel : (34) 91 457 48 91
Fax : (34) 91 458 10 88
E-mail : cherrasti@siasa.es

Registration form

Please complete one form per person. (Please print).

_____Mr. _____Ms.

First Name:_____________________________________

Surname:_______________________________________

Age: Under 30 ___  30-50 ___  50-65 ___  65-80 ____ Over 80____

Nationality:__________________________________________________

Please note that you are responsible for securing the applicable entry visas for Spain. Should you require additional information, please contact the Spanish Consulate nearest you.

Name of Organization:

_____________________________________________________

Position:

_________________________________________________________

Street Address:

___________________________________________________

City:________________________________

State:____________________

Province: __________________ Country: ____________________

Postal Code: ________________________ 

Telephone: _______________________

Fax: _____________________E-Mail: _______________________

Website: _________________________________________________

Please mark the regions below where your organization operates or works with affiliates :     

_____ Africa

_____ Latin America and Caribbean

_____ Asia Pacific

_____ Europe

_____ Western Asia

_____ North America

Please indicate the number of countries where your organization operates or works with affiliates. _____

If your organization is a member of a network, consortium or other group, please indicate so here.

__________________________________

Are you interested in arranging an activity for the Forum?

_____ Yes_____ No

If so, please indicate which activities.

_____ Workshop

_____ Conference

_____ Round Table

_____ Other, Please Specify:

___________________________________________________________

Please indicate if you are interested in organizing a Stand (Booth):

______

Please indicate the language you prefer to use.

Spanish ____ English _____ French _____ German _____  II
Other :_____________

Please indicate the main topic of this activity:

_____________________________________________

Are you interested in participating in a Work Group during the Forum?

_____ Yes_____ No

If so, please indicate your Work Group preference.
(1=most preferred; 6=least preferred)

_____ Public Policy on Ageing and the Well-Being of Society

_____ Older Persons' Rights

_____ Environmental Issues

_____ Culture, Training, Participation and Leisure

_____ Poverty, Development and Ageing

_____ Healthcare

Participant’s registration fee

After February 15, 2002: 125 Euros

Payment will only be accepted in Euros. The Registration Fee allows participants to: Attend opening and closing sessions, work sessions, welcome reception, conferences, workshops and round table sessions, and receive the Forum documentation. Cancellations must be received in writing prior to 1st March 2002, and only 50% of payment will be refunded.

Method of Payment: please check only one option :

Credit Card:

Card Type: American Express, VISA, Mastercard, Diner's Club, Other…

Specify Owner:

 ______________________________________________________

Card Number: ___________________________

Expiration Date: _______________________

Bank Draft: Personal checks and Eurocheques will not be accepted. Bank Drafts must be sent free of charges and issued by a bank with a branch located in Madrid.

Bank Drafts should be made out to: Foro Mundial ONG sobre Envejecimiento

Bank Wire Transfer: Please send your payment free of charges to:
                    Purpose: Registration in NGO World Forum on Ageing

 Bank Name: Caja Madrid

 Address: Pza. del Celenque, 2.  28013 Madrid, España

 Account Number: 2038-0-603-21-6006438159

 SWIFT: CAHMESMMXXX

 Reference: Please include participant's name.

Date of Registration: ___________

Please send your bank draft or a copy of the bank wire transfer with this Registration Form to:

SIASA VIAJES, S.A.

Paseo de la Habana, 13428036

Madrid, Spain

Tel: 3491 457 48 91 Fax: 3491 458 10 88

Email: cherrasti@siasa.es

*Note: Before sending this information, please carefully review your responses and keep a copy of this form for your records.

**Note: If you have any questions regarding forum registration please email the NGO forum organizers: forumageing@servimedia.es