Club Membership Form Template s2

Civil and Water Engineering Conference

Date: 3-4 November, 2017 | Venue: BIAM Foundation, Eskaton, Dhaka, Bangladesh

Conference Registration Form(Local Author)

All participants are required to complete this registration form and return in MS Word format to Ms. Nuha Jahan via [email protected] or Fax to: +61 3 9702 0122 by 8 December 2016

SECTION 1: CONTACT INFORMATION

TITLE: Mr Mrs Miss Ms Dr Prof. Other, specify: FIRST NAME: LAST NAME:

ADDRESS: MAIN TELEPHONE: WORK TELEPHONE (if HOME TELEPHONE TOWN/CITY: MOBILE PHONE:

POST CODE; PRIMARY EMAIL:

COUNTRY; SECONDARY EMAIL: FACULTY/DEPARTMENT/SCHOO L: AFFILIATION (NAME OF UNIVERSITY/INSTITUTE): BROAD FIELD OF RESEARCH (eg. Banking, Management, etc): Are you willing to serve as a Are you willing to work Yes No Yes No session chair: as a reviewer: How did you hear about this Direct Email Websites (Please Specify) : conference? Other (Please Specify) : SECTION 2: PAPER PRESENTATION

Are you presenting a paper If you are presenting Presenting Paper or participating as an a paper, how many 1 2 Observer ONLY observer? are you presenting? Please provide the paper Do you have a Yes No number(s) assigned to you preference for paper If Yes- which presentation date? in the acceptance letter(s): date: (Please note we may not be Would you like your paper to Yes No 3 Nov 4 Nov be included in the online refereed conference If Yes- Please choose what you would like to upload to the proceedings? Abstract Full Paper

SECTION 3: PAYMENT INFORMATION Please indicate which code and description you are paying for (refer to the fee schedule) and tick the payment option you choose to pay by. For credit card payments, please fill in all relevant information below. Code: Descriptio Amoun Tk. n: t: Credit Card International Transfer Paypal Pay to: [email protected] (for Pay to: Research and Type of Card: Mastercard Paypal account Holders) Visa Publications Organization

Current Deposit Account No.: OR Name on Card: 0200010242197 Email: Nuha Jahan via Card Number: Agrani Bank Limited [email protected] For non Paypal account holders for Badda Branch Expiry Date: an invoice to be emailed to you PLEASE NOTE: The Credit Western Union Card will be processed by Please Quote MTCN: Dhaka, Bangladesh Business Care Australia Pty Ltd, Australia Money Gram Please Quote Ref. No: Declaration: I HEREBY DECLARE THAT THE ABOVE INFORMATION ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. SIGNED: (or write name DATE: here) PLEASE NOTE: Receipts will be provided on the conference registration day (3 Nov, 2017 unless urgently required.