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LAST DATE FOR REGISTRATION – 16th SEPTEMBER 2007

Title Dr Mr Ms First Name* Last Name* Designation* Department Organization* Address* City* State* Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Faeroe Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Occupied Palestinian Territory Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of Korea Republic of Moldova Réunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Province of China Tajikistan 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 Republic of Tanzania United States United States Virgin Islands Uruguay Uzbekistan Vanuatu Venezuela VietNam Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe Postal Code* Fax Telephone* E-mail* No of Participants       Additional Information Required from Overseas Participants Name (as mentioned in the passport)* Father's/ Husband Name* Passport No*. Date of Issue* Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb March April May June July Aug Sept Oct Nov Dec Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 Place of Issue* Valid up to* Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb March April May June July Aug Sept Oct Nov Dec Year 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 Date of Birth* Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb March April May June July Aug Sept Oct Nov Dec Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 Birth Place* Citizenship* REGISTRATION FEE PER PARTICIPANT   Indian delegates (in Indian Rupees) International delegates (in US Dollars) CATEGORIES Single Participant 2 3 4 5 Participants Single Participant 2 3 4 5 Participants Corporates 5000 300 Autonomous/ Semi-autonomous Institutions/ Government & Public Sector Undertakings/ Bilateral Agencies/ Sponsors/ Exhibitors 3000 250 NGOs/ CSOs / CBOs, Individual Participants, Academic Institutions 1500 150 WTO/ SSA Members *     125           *   WTO – World Toilet Organisation SSA – Sustainable Sanitation Alliance Mode of Payment Bank Transfer Demand Draft Indian Participants HDFC Bank, Mahavir Enclave Branch, Palam Dabri Road, New Delhi – 110045, INDIA Account No.1322000008002 Overseas Participants State Bank of Indore, Janak Puri Branch, New Delhi-110058, INDIA Account Number –53009782621 Swift Code –STININBB203 In favour of Sulabh International Academy of Environmental Sanitation, payable at New Delhi. MAIL TO Sulabh International Academy of Environmental Sanitation Sulabh Gram, Mahavir Enclave, Palam-Dabri Road, New Delhi – 110045, INDIA Fax No.( +91-11) 45521733, Email : registration@worldtoiletsummit2007.org Kindly Note: Registration fee is non-refundable Changes in nominations are acceptable Dollar (US) fee is applicable to all foreign nationals Fee is on non-residential basis Government Taxes Extra as applicable. Confirmation of registration is possible only if the form is received with the fee and is subject to space availability I Agree to Pay