FAVA 2008

REGISTRATION FORM

The 15^th FAVA Congress 2008 27-28-29-30 October 2008

PLEASE PRINT OR TYPE (Black ink and block letter only)

∇ PERSONAL DETAILS

* First Name:

Middle Initial:

* Last Name:

* Title:

* Badge Name:

* Organization/Institute:

* Department:

* Mailling Address:

* Street:

* City:

State:

* Zip Code:

* Country:

* Email Address:

Mobile Number:

* Area Code/Phone Number:

Fax Number:

Special Dietary Requirement:

*Veterinary Student / Graduate Student Eligibility
I certify that the above-named person is presently veterinary student or graduate student.
Name of Department Head (please print name):		Email Address:


∇ REGISTRATION FEES (in US Dollars)

Name of accompanying person 1:
Name of accompanying person 2:

∇ METHOD OF PAYMENT

Payment Reference:

Grand Total Fees Payable (I+II+III) USD

Please identify your payment method:

Bank Transfer (including bank charges)

Ref. Code:

From Bank:

Branch:

Country:

For Bank Transfer, please transfer to: Account name: 15th FAVA CONGRESS, Account number (IBAN Code): 374-1-52292-4

Swift code: AYUDTHBK, Name of Bank: Bank of Ayudhya, 50 Phahonyothin Road, Ladyao, Chatuchak, Bangkok 10900, Thailand.

Credit Card (please complete your payment details)

Name on card: