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Registration Form - AIBBC 2019

Registration

Registration Form - AIBBC 2019

Please fill in blanks and click confirmation.
* indicates required field.

Title*
Last name*
First Name*
Middle Name
E-mail Address*
E-mail Address(Confirmation)*
Affiliation - Institution*
Affiliation - Department*
Position (choose your position)*
Country (select country)*
Physical address*
AIBBC MEMBERSHIP (Select one)*
Abstract Submission*	YES NO
If yes, enter abstract title*
Attendance (Select one from below)*
Expected date of arrival*
Will you require accommodation In Nairobi *	YES NO
Will you require accommodation In Mombasa*	YES NO
Do you have accompanying persons	YES NO
If YES, How many
Will you need accommodation for accompanying persons
Dietary restrictions/Special requests (We will try to meet your request but not guaranteed)
If Others, specify
Fee Category *	Local student participant (MEMBER *1)　Ksh. 3000 or USD 30 Local student participant (NON-MEMBER)　Ksh. 5000 or USD 50 Local general participant (MEMBER)　Ksh. 12000 or USD 120 Local general participant (NON-MEMBER)　Ksh. 17000 or USD 170 International student participant (MEMBER)　Ksh. 12000 or USD 120 International student participant (NON-MEMBER)　Ksh. 17000 or USD 170 International general participant (MEMBER)　Ksh. 27000 or USD 270 International general participant (NON-MEMBER)　Ksh. 32000 or USD 320
SELECT*	Bank transfer Cash payment onsite
Expected date of transfer（yyyy/mm/dd）*

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