Registration Form

This entire page is under construction until Toronto conference information is received.

Registration Form

PAP-ICP Convention

July 1-5, 2002

Manila, Philippines

Deadline: 31 May, 2002

Mail to:

Dr. Naty Dayan / ICP Registration, Dayan’s Psychological Clinic ; Suite 2103 V.V. Soliven Shopping Complex, Edsa San Juan; Metro Manila, Philippines

Telephone Numbers: 721-7133 / 724-5358

Email: bereps@pacific.net.ph

DELEGATE REGISTRATION

Attach a Business Card or Please print clearly all of the following information:

Dr._______	Professor_______	Ms. _______		Mr. _______	Mrs. _______
Others _______

Lastname: ________________________________			Given Name ________________________________

Organization/Department: __________________________________________________

Preferred address for correspondence: Office Address_____ Home Address_____
Please give your country code for phone + fax

Address:
Street Address __________________________________
City ________________________________ State ______________________
ZipCode __________________________________			Country __________________________________

OfficePhone _______________________________			OfficeFax ________________________________
HomePhone ______________________________
Email ___________________________________

Preferred Name on Badge: __________________________________________________

Special Dietary requirements (Please specify): ________________________________________

Please detail any disability requirements (i.e. preference for ground floor room, etc.):
_____________________________________________________________

Accompanying Person Registration

Preferred Name on Badge: __________________________________________________

Special Dietary requirements (Please specify): ________________________________________

Please detail any disability requirements (i.e. preference for ground floor room, etc.):
_____________________________________________________________

Currency: in American dollars

	*Early Registration*	After April 7, 2002
ICP regular member	US$200.	US$220.

ICP member from developing countries	US$75.	US$100.

PAP members / Students	US$100.	US$120.

Accompanying person	US$150.	US$170.

Non member	US$220.	US$240.

Non member from Category C Countries (non-subsidized)	US$120.	US$140.

Registration fee includes an admission to the opening reception, program, and abstracts.
Conference rates also include morning tea/coffee and biscuits; 2 lunches; afternoon tea/coffee and cakes and local taxes for both days.


Please check payment method (payment is in US dollars):

Cheque enclosed ____ (payable to ICP)	Money Order _____

Bank/Wire Transfer ______
Wire transfer can be made directly to:
NATIVIDAD A. DAYAN, 2287-00093-9, Equitable PCI Bank, West Trade Center, West Ave. Branch Swith Code: PCIBPHMM

Credit Card: _____ (Please complete the details below)

Type of Card: Mastercard _______ Visa _______

Cardholder Name: ____________________________________________________
Name of Organization Issuing Card: _____________________________________________
Postal Address: __________________________________________________________________
_______________________________________________________________________
Telephone Number: ______________________________

Card Issue Number: ___________________
Card Number: ______________________________________________
Cardholders Name and Initials as on card: __________________ ___________________________
Card Expiry Date : _________________________ (MM/YY)

Signature: __________________________________________________________________________
Billing Address (Please print legibly):

Street Address: _____________________________
______________________________
______________________________

City/State: ___________________________________	Country: __________________________

Mail to: Dr. Naty Dayan / ICP Registration, Dayan’s Psychological Clinic ; Suite 2103 V.V. Soliven Shopping Complex, Edsa San Juan; Metro Manila, Philippines





For further information, check out the following website or contact:

Dr. Antoinette D. Thomas (Scientific Chair) 100 de Normandie ; St. Lamber, PQ, J4x 1T4 Canada

ICP website: http://www.geocities.com/icpsych This will link you to the 2002 ICP-PAP Convention

Web Editor, Walter.Griesinger@uc.edu