ICML + AHILA 2021 Congress Registration Form PLEASE FILL IN ALL FIELDSRM_Stats PLEASE ENTER NAME AND INFORMATION EXACTLY AS THEY APPEAR ON YOUR ID/PASSPORT. Surname/Last Name *First Name *Passport/ ID number *Country *--Select Country--AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas, TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCote D'ivoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia, TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and the McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIraqIranIrelandIsle Of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Republic OfKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, The Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandTaiwanTajikistanTanzania, United Republic OfThailandTimor-lesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe PLEASE ENTER YOUR OFFICIAL/WORK CONTACT INFORMATION BELOW. Name of Employer/ Affiliation *Current Position/ Professional *Title *Office Address Address Line 1 * Address Line 2 City * State or Region * Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and the McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iraq Iran Ireland Isle Of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Republic Of Kosovo Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Taiwan Tajikistan Tanzania, United Republic Of Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country * Zip Primary Email Address *Primary Phone Number * PLEASE SELECT THE APPLICABLE TYPE OF REGISTRATION Registration Type *Select an optionDay Delegate/AHILA Member - USD ($ 150)Day Delegate/Non Member - USD ($ 180)Early Bird AHILA Member - USD ($ 300)Early Bird Non Member - USD ($ 350)Standard - USD ($ 400)Onsite/AHILA Member - USD ($ 450)Onsite/Non Member - USD ($ 500)Student - USD ($ 200)Virtual/Online Delegate - USD ($ 200)Registration fees cover the following: Conference bag (that comes with some promotional materials from selected sponsors) Abstract and programme book Plenary and open track sessions Opening and Closing ceremony Lunches and Refreshments Access to the Exhibition area NOTE: Due to COVID19 if this event is hosted via blende approach (both virtual and on site) will you still be interested in attending? * Yes No *Those presenting a paper fall under IAALD Member.*Payment for early registration is due before 28 February 2021*Payment for standard registration should be received between 1 and 31 March 2021*Payment for late registration is due on 20 April 2021*All payments after 31 March 2021 are for late registration.*email copy student ID to amanda@itoca.org for student registrations.*all AHILA members to send proof of membership to chiedza@itoca.org All payments are via bank deposits or wire transfer made into the following account: Bank Name: First National Bank (FNB)Account Name: ITOCA- Info Training & Outreach Centre for AfricaAccount number: 62683040548Bank branch code: 250149Branch Address: FNB Forex, Business Banking, 30 Diagonal Street, FNB Place, 9th Floor, Pretoria, South AfricaSwift code: FIRNZAJJAccount currency: US Dollars *For payment in South African Rand equivalent and rates for Exhibitors, please contact amanda@itoca.org Cancellation Policy: Requests for conference registration cancellation must be received in writing by mail by 30 April 2021. The conference registration fee will be refunded after the conference less 25% administration costs, this is applicable for cancellations done before 30 April 2021. Requests received after 30 April 2021 will not be processed or refunded. "No shows" are non-refundable and are liable for the full registration. If you cannot attend, you may send a substitute person. The original registrant must submit a written authorization for such a change. ii) Proof of payment made by bank deposits or wire transfer must be sent to the Conference Registration Coordinator to enable her to keep track of the transactions. iii) The same names used on this registration form must appear on the proof of payment. iv) All registration fees paid on-site will be in South African Rand. v) Payment for all registrations after 31 March 2021 will be done on-site. vi) Invoices for all payments will be available for collection during the conference at the registration desk. I agree *I acknowledge that I commit myself to the payment of the applicable full conference fee. I have taken notice of the cancellation terms on this formSelect a payment method * Pay Offline Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu.