REGISTRATION FORM ===================================================================================== INDABA 5 - Models, Mysteries and Magic of Molecules 20-25 AUGUST 2006 ===================================================================================== Title: _ _ _ _ _ First Name(s): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Surname: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Department: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Organisation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Postal Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ e-mail: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Tel: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Fax: _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ ===================================================================================== I will be accompanied by: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Preferred accomodation: Type A Type B Type C (student) Single _ _ _ Share +1 _ _ _ Share +4 _ _ _ I would like to share with: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ===================================================================================== PRESENTATION: Poster _ _ _ _ Oral _ _ _ _ None _ _ _ _ Provisional Title:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ===================================================================================== TRAVEL DETAILS: Bus transport from Johannesburg Int. Airport to Berg-en-Dal (& rtn) Yes _ _ No _ _ Bus transport for sightseeing during the duration of Indaba 5 only Yes _ _ No _ _ ===================================================================================== CANCELLATIONS: The following refunds will apply: Cancellation before 30th June | 50% Cancellation after 30th June | No refund =====================================================================================