I.R. Iran CO
Registration Form
Training on No Scalpel Vasectomy
19-30 November 2011, Urmia, I.R. of Iran
DELEGATE DETAILS
PERSONAL DETAILS
Title: (Please specify – e.g. Dr; Mr; Ms; Mrs; other)
Surname: Other names: Gender: male / female
CONTACT DETAILS
Position: Department:
Organisation:
Address:
City/Town: State/Province/Country Postcode
Phone: Fax:
E-mail: Web:
FLIGHT DETAILS
Arrival date: Flight No. Time____________________
Departure date: Flight No. Time
ACCOMMODATION DETAILS
Single room Double room______________________________________________________
Check-in date Check-out date____________________________________________________
REMARK
Is disability assistance required? (please specify)
Other special requirements (e.g. dietary): (please specify)
REGISTRATION (closing 22nd October, 2011)
Please complete and e-mail this form to Ms. Minoo Darvishzadeh at darvishzadeh@unfpa.org or fax it to +98 21 2285 7485
Please also contact Minoo with any inquiries that you might have. Her direct phone number is +98 21 2285 2583.