Sexuality Conference

Self, Selves and Sexualities

Conference Registration

* Fields in red are mandatory.

Professional Title:

First Name:

Surname:

Gender:

Street Address:

City:

E-mail Address:

Telephone:

Please indicate if you have any special dietary needs that need to be taken into consideration:

WE ONLY ACCEPT PERSONAL LASER, MASTERCARD and VISA, CREDIT/DEBIT CARDS.

WE DO NOT ACCEPT INSTITUTIONAL CREDIT CARDS.

WE DO NOT ACCEPT CHEQUES.

Type of Registration	Cost	Tick to Attend
Non-DCU Delegate (early fee)	€ 200.00
Non-DCU Delegate (late fee)	€ 250.00
DCU Delegate (early fee)	€ 80.00
DCU Delegate (late fee)	€ 100.00
DCU or Non DCU Student (early fee)	€ 50.00
DCU or Non DCU Student (late fee)	€ 100.00
Unwaged	€ 50.00
Retired	€ 50.00

Late Fee registration applies from : Friday January 13th 2012

TOTAL AMOUNT PAYABLE:

Name (as on credit card) :
Credit Card Type
Credit Card Number:
CVN number	Not required for LASER
Expiry Date:
Billing Address for credit card:

Please note that payment can be made, in cash, in Euro only at Registration
Visa Request Information

A conference visa support letter when necessary, after reception of payment only,
An attendance certificate,
A receipt of payment at registration only.