East Central and Southern Africa (ECSA) Health Community
8th BEST PRACTICES FORUM AND 24th DIRECTORS’ JOINT CONSULTATIVE COMMITTEE
PARTICIPANT REGISTRATION FORM
Dates: 11th – 13th August 2014. Venue: Arusha Tanzania
Theme:
ECSA Health Community at 40: Strengthening Regional Cooperation for Better Health Outcomes
This form is to be filled by anyone who wants to attend the ECSA Health Community 8th Best Practices Forum and 24th Directors’ Joint Consultative Committee.
SECTION 1: PERSONAL INFORMATION
*First Name: Middle Name/Initial:
*Last Name:
Qualification(s) (e.g., Ph.D): Title (e.g., Mr, Ms, Prof, Dr)
*Job Title:
*Affiliated Organization/Institution:
*Mailing Address:
*City: *Country:
*Nationality: *Country of residence:
*Gender: Male Female: *E-mail Address (Primary):
ECSA Health Community: P. O. Box 1009 Arusha Tanzania +255 27 2549362/5/6, Email: [email protected] Website: www.ecsahc.org 1 E-mail address (Secondary):
*Main Phone Number and Type: Office Direct, Main Office, Home, Cell (Circle)
2nd Phone Number and Type: Office Direct, Main Office, Home, Cell (Circle) 3rd Phone Number and Type: Office Direct, Main Office, Home, Cell (Circle) Fax, if available: Skype name, if available:
*Required fields. SECTION 2: FUNDING AND ATTENDANCE INFORMATION
EVERYONE must fill in this section
1 Please indicate your funding source: Self Employer / Donor Organization Other, state: 2 I wish to pay my conference costs and fees Direct transfer to ECSA’s account (see details by: in section 3) Banker’s draft Cash on arrival Other, state: 3 When attending the conference in Arusha, I ■City: will be travelling from (City, Country): ■Country:
4 Do you require assistance with any of the Accommodation in Arusha following If ticked, please give dates required:
NB. In this case, please note that we must receive your hotel payment together with your conference registration fees to guarantee you a reservation. Please read about the available hotels and their rates before you register.
Visa to Tanzania
If ticked, indicate if visa letter required: Yes
Transport from airport to the hotel: If ticked, give details of airline, flight number and arrival day and estimated time:
ECSA Health Community: P. O. Box 1009 Arusha Tanzania +255 27 2549362/5/6, Email: [email protected] Website: www.ecsahc.org 2 SECTION 3: CONFERENCE COSTS AND PAYMENT INFORMATION:
This form is designed to find out if you are planning to attend the ECSA Health Community 8th Best Practices Forum and 24th Directors’ Joint Consultative Committee and will assist us in planning the conference. Payment information is required.
All conference attendees are individually responsible for their conference attendance costs.
The costs of attending the conference are as follows: Cost per participant excluding accommodation and air travel: US$ 350. This includes all conference-provided meals other meeting costs, administrative costs and conference fee of $100 per participant). ECSA Health Community fully sponsored participants may ignore this section but fill up the registration form for to help us in the planning process
Modalities of payment for the conference:
Direct transfer to ECSA’s Bank Account, details as follows:
BANK DETAILS
BANK NAME: STANDARD CHARTERED BANK (T) LTD
BRANCH: ARUSHA
ADDRESS: GOLIONDOI ROAD, ARUSHA
POSTAL CODE: P. O. BOX 3000
COUNTRY: TANZANIA TELEPHONE: +255 (27) 2544704
FAX: +255 (27) 2544708
SWIFT/ABA CODE: SCBLTZT
ACCOUNT CODE: 87 400 140535 00
ACCOUNT BENEFICIARY: COMMONWEALTH REGIONAL HEALTH COMMUNITY SECRETARIAT
Please check carefully that you have entered the account number and codes exactly as above to avoid any delays in your payment and any associated problems regarding your attendance.
We regret that we do not have online payment facilities and automatic payment receipts system tied to our account set up as yet, and so we strongly advise that when paying into the ECSA’s account, you provide conference registration name as a reference or other identifying information, and in addition, please send a mail to [email protected] to notify the conference management of your payment including the reference information provided. A receipt will then be sent to you on verification of the payment. You will need to produce this receipt on arrival at the conference registration desk.
ECSA Health Community: P. O. Box 1009 Arusha Tanzania +255 27 2549362/5/6, Email: [email protected] Website: www.ecsahc.org 3 Please do not travel to the conference without having paid in advance, or received permission in advance to pay on site.
**Please send your completed form in MS Word format (NOT PDF) to: [email protected]
SECTION 4: CONFERENCE AND HOTEL COSTS
Hotel reservation
ECSA Health Community will make all arrangements with the hotels listed below for specific rates for participants for the period of the conference. All accommodation is Bed & Breakfast.
1. Snow Crest Hotel 2. Mount Meru Hotel 3. Kibo Palace Hotel 4. New Arusha Hotel 5. Palace Hotel 6. East Africa Hotel
To book your choice of hotel, you can either contact the hotel directly or send a mail to ECSA Health Community Secretariat, and we shall assist you.
If you prefer that ECSA Health Community reserves your accommodation, please indicate the name of the hotel of your choice, The room rate of your choice, The total number of days and The total amount due in US$
If you intend to reserve your accommodation through ECSA, please note that your reservation will only be confirmed after you transfer the total amount to the ECSA bank account (details as above). You will receive a confirmation receipt upon payment, which you should produce at the conference registration desk.
Miscellaneous Please let us know if you have any special dietary requirements: Yes No If "Yes" please specify:
ECSA Health Community: P. O. Box 1009 Arusha Tanzania +255 27 2549362/5/6, Email: [email protected] Website: www.ecsahc.org 4