REGISTRATION FORM
ROTARY DISTRICT 7030 – PETS & CONFERENCE 2015
8 - 11 April 2015 (PETS 8/9 APRIL)
PLEASE COMPLETE ALL SECTIONS.
1. MAIN REGISTRANT DETAILS
Membership ID (required for Rotarians)
Family Name
First Name
Middle Initial
Name or Nickname to be printed on badge
Club Name andCity
Classification (Rotarians only)
Country
District
Contact Information. Please provide your current mailing address.
Street Address or P.O. Box
City:
Business Phone (please include country and city codes)
Country:
Home Phone
Fax
Email (Required):
Emergency Contact during the meeting (required):
Phone (include country and city codes)
Name
Language Preference
Dutch
English
French
Registration Category Selection
Conference Registration Category (select one):
Rotarian Partner in Service Rotaractor
2.
GUEST REGISTRANT DETAILS
Registration Categories
1 Partner in Service 2 Rotaractor 3 Other
Guest 1 Category # …… (see above)
Guest 2 Category # ….. (see above)
Guest 3 Category # ….. (see above)
Family Name:
Family Name
Family Name
First Name:
First Name
First Name
Middle Initial:
Middle Initial
Middle Initial
Name or Nickname to be printed on badge:
Name or Nickname to be printed on badge
Name or Nickname to be printed on badge
Club/City
Club/City
Club/City
Country
Country
Country
Page 1 of 3
3. CONFERENCE REGISTRATION FEES (All prices are in U.S. dollars and inclusive of tax)
Register Early and Save!
Registration Category
Deadline 1:
1 December 2014
Deadline 2:
1 March 2015
After 1 March 2015
(On-site or Online)
Rotarian
US$ 250
US$ 200
US$ 200
US$ 300
US$ 250
US$ 200
US$ 350
US$ 300
US$ 200
Partner in Service
Rotaractor
Total Registrants
by Category
Total Due:
Total (Total
Registrants x Fee)
US$
4. T-SHIRT (check one for each registrant)
Size
Small
Medium
Large
X-large
XX-large
5. FLIGHT INFORMATION
DATE
TIME
TO/FROM
BY
CAR/AIRPLANE/OTHER
ARRIVAL
DEPARTURE
6. HOTEL/ACCOMMODATION (* conference hotels: transportation to and from this hotels only)
1
2
3
4
5
6
7
8
NAME OF HOTEL/OTHER
(select one)
Torarica Hotel & Casino Hotel*
Royal Torarica Hotel*
Eco Resort Inn*
Hotel Krasnapolsky*
Courtyard Marriott Paramaribo*
Residence Inn*
Ramada Paramaribo Princess Hotel*
Zeelandia Suites*
ARRIVAL DATE
DEPARTURE DATE
NUMBER OF
GUESTS
Page 2 of 3
7. PAYMENT AND SIGNATURE
All fees must be submitted with this signed registration form and paid in U.S. dollars. The DC Treasurer will accept payment.
PAYMENT CAN BE MADE BY ELECTRONIC MONEY TRANSFER (RECOMMENDED) OR BY CREDIT CARD.
Payment by Money Transfer
BENEFICIARY INFORMATION
BENEFICIARY BANK INFORMATION
INTERBANK INFORMATION (USD)
Account number: 2400001000354307
Name
: Rotary District 7030
Adress
: Rio de Janeirostraat 15
Paramaribo, Suriname
SWIFT Code: RBTTSRPA
Name
: RBC Royal Bank Suriname
Adress
: Kerkplein 1
Paramaribo, Suriname
SWIFT BIC Code: PNBPUS3NNYC
Name
: Wells Fargo Bank (NY International branch)
Adress
: 11 Penn Plaza 4th Floor
New York NY 10001 USA
*Note: the sender pays all wire transfer fees
Payment by Credit Card
Credit Card Type
Card Number:
Visa
Cardholder’s Name (as it appears on card)
Fax your Registration Form with Credit Card info to:
Expiration Date (mm/yyyy)
Fax number: +597 441400
Mastercard
Security Code (3 or 4 digits)
Signature (if different from below)
For the Attention of: DG Elwin Atmodimedjo
*Note: a 5% bank fee will be charged separately to the credit card
By signing, I submit my registration and I verify that I have read and agree to the conditions noted above (* see above in red) and the
cancellation policy (**see below).
Signature:
……………………………………………………………………….
Date:
………………………………….……………………………..
**CANCELLATION AND CHANGES
All registration cancellations are subject to a US$50,- service fee.
Requests to cancel registration must be received by 01 March 2015. Cancellations requests received after that date will not be eligible for
reimbursement of any fees paid or other costs incurred.
VISA AND TOURIST CARD
Please check if you need a visa or tourist card. http://www.surinameembassy.org/visa_extension.shtml
THREE WAYS TO REGISTER!
1. Register online at www.clubrunner.ca/7030
2. Fax the registration form to +597 441400 For the Attention of: DG Elwin Atmodimedjo (RECOMMENDED IF PAYMENT IS MADE BY CREDIT CARD)
3. Email the form to [email protected]
Please note: Allow 1-2 weeks for processing of faxed or emailed forms. The DC office will email all confirmations.
Page 3 of 3