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4th Annual American Business Research Conference Date: 4-5 June, 2012 | Venue: Adelphi University, Manhattan, NY, USA Conference Registration Form All participants are required to complete this registration form and return in MS Word format to Ms. Nuha Jahan via email@example.com or Fax to: +61 3 9702 0122 SECTION 1: CONTACT INFORMATION TITLE: Mr Mrs Miss Ms Dr Prof. Other, specify: FIRST NAME: LAST NAME: ADDRESS: MAIN TELEPHONE: WORK TELEPHONE (if different) HOME TELEPHONE TOWN/CITY: MOBILE PHONE: POST CODE; PRIMARY EMAIL: SECONDARY COUNTRY; EMAIL: FACULTY/DEPARTMENT/SCHOOL: AFFILIATION (NAME OF UNIVERSITY/INSTITUTE): BROAD FIELD OF RESEARCH (eg. Banking, Management, etc): Are you willing to serve as a Are you willing to work as Yes No Yes No session chair: a reviewer: How did you hear about this Direct Email Websites (Please Specify) : conference? Other (Please Specifiy) : SECTION 2: PAPER PRESENTATION If you are presenting a Are you presenting a paper or Presenting Paper paper, how many are you 1 2 participating as an observer? Observer presenting? Please provide the paper Do you have a Yes No number(s) assigned to you in the preference for paper If Yes- which date: acceptance letter(s): presentation date? 4 June 5 June Yes No Would you like your paper to be included in the online refereed If Yes- Please choose what you would like to upload to the proceedings conference proceedings? Abstract Full Paper SECTION 3: PAYMENT INFORMATION Please indicate which code and description you are paying for (refer to the fee schedule) and tick the payment option you choose to pay by. For credit card payments, please fill in all relevant information below. Code: Description: Amount: USD $ Credit Card International Transfer Paypal Pay to: firstname.lastname@example.org (for Type of Card: Mastercard Visa Pay to: World Business Institute Paypal account Holders) Name on Card: Branch No: 033609 | Account No. 382353 OR Email: Nuha Jahan via Card Number: Swift Code: WPACAU2S email@example.com For non Paypal account holders for an Expiry Date: Bank Name: Westpac Banking Corporation invoice to be emailed to you PLEASE NOTE: The Credit Card Address: 27 High Street, Berwick, will be processed by Business Care Melbourne, Victoria 3806, Australia Australia Pty Ltd, Australia Declaration: I HEREBY DECLARE THAT THE ABOVE INFORMATION ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. SIGNED: DATE: (or write name here) PLEASE NOTE: Receipts will be provided on the conference registration day (4 June 2012) unless urgently required.
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