SEAMEO Regional Centre for History and Tradition

ANNUAL PROGRAMMEStudy of Mon Society and Culture

REGISTRATION FORM

Please print and return this form to : SEAMEO Regional Centre for History and TraditionPyay Road, Yangon, 11041, MyanmarFax: 95-01-515175E-mail: <seameo_chat@mptmail.net.mm>< winnaw@gmail.com>

<siblutnaw@gmail.com>

__________________________________________________________________________________________

I wish to register for the Study of Mon Society and Culture programme to be conducted from 18 to 24 March 2015.

Please tick the appropriate one.

Title: Prof. Dr. Mr. Mrs. Ms. others (Please specify) __________________________

First name: _________________________________________ Middle name: ___________________________

Last name: _________________________________________ Father’s name: __________________________

Sex: Male Female

Citizenship: _________________ Date of Birth: _____________________ Place of Birth: _______________

Passport No: _________________________ Date of issue: ________________________________________

Date of expiratory: ___________________ Place of issue: ________________________________________

Designation:_______________________________________________________________________________

Academic qualification: ______________________________________________________________________

Institution/ Organization: _____________________________________________________________________

__________________________________________________________________________________________

Contact Address:____________________________________________________________________________

City: ______________________________ Post Code____________________ Country : __________________

Telephone no. Office : _______________________________ Residence : ______________________________

Fax : ___________________________________ E-mail : __________________________________

Name:_________________________________

Signature:_______________________________

( NOTE: Registration deadline is 4 February 2015)