ROTARY INTERNATIONAL
DISTRICT 9100
34th DISTRICT ASSEMBLY AND CONFERENCE
April 29 to 03 May 2008, ACCRA, GHANA
34eme ASSEMBLEE ET CONFERENCE DE DISTRICT
Du 29 avril au 03 mai 2008 a ACCRA, GHANA
REGISTRATION FORM / FORMULAIRE D'INSCRIPTION
Family Name / Nom:
*
First Name / Prénoms:
*
Rotary Name / Badge:
*
In Country / Ce pays
*
Select Country
Benin
Burkina Faso
Cape Verde
Gambia
Ghana
Guinea
Guinea-Bissau
Ivory Coast
Liberia
Mali
Niger
Senegal
Sierra Leone
Togo
Rotary Club of / Rotary Club de:
*
Email Address / Addresse Email:
*
Classification:
*
Yes/Oui
No/Non
Current office held in club /
Fonctions dans le club:
*
Yes/Oui
No/Non
Past Office held in club or district /
Fonctions déjá exercées dans le club ou district:
*
Select / Choisis
1st time / 1re fois
2nd time / 2e fois
3rd time / 3e fois
4th time / 4e fois
5th to 9th time / 5e á 9e fois
Over 10 times / +10 fois
Participation DAC /
Participation ACD:
Yes/Oui
No/Non
Participation Home Hospitality:
Yes/Oui
No/Non
Paul Harris Fellow:
1.
Select / Choisis
Spouse
Child
Other
2.
Select / Choisis
Spouse
Child
Other
3.
Select / Choisis
Spouse
Child
Other
4.
Select / Choisis
Spouse
Child
Other
GUESTS / INVITÉS:
PROPOSE PACKAGE / PACK PROPOSÉ
=
1
2
3
4
5
USD 25 X
DAC registration / Inscription ACD:
=
1
2
3
4
5
USD 50 X
Governor's Gala / Gala du Gouverneur:
=
1
2
3
4
5
USD 25 X
PHF Lunch / Dejeuner PHF:
=
1
2
3
4
5
USD 100 X
Hotel Reservation / Reservation de l'hotel:
Total USD
Special Needs (diet, medical etc.) Besoins spéciaux (alimentaires, médicaux, etc.):
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