Registration Form for the 13th

INWEPF Steering Meeting and Symposium

Phnom Penh & Siem Reap– Cambodia – 6-8 December 2016

Delegate Information

Title Mr. ( ) Mrs. ( ) Ms. ( ) Dr. ( ) Prof.( )

Name Passport No.

Country Gender Male ( ) Female ( )

Position

Organization

Address

City Zip Code

Email Fax

Phone Mobile phone

Date of Birth (Month/Date/Year)

Type of Participation

Presentation ( ) Local organization Nominee ( )

Country Representative ( ) General Participant ( )

Photo

Hotel Reservation (Foreign participants only )

Hotel Type

Cambodiana Hotel in Phnom Penh ( )

Angkor Century Hotel in Siem Reap ( )

Room

Type

Check in Date Check out Date

Participation to Field Visit

Yes

No

Remarks Vegetarian ( ) Non- Vegetarian ( ) Halal only ( )

Attach a photo