AC21: 3rd Biennial International Research Festival
4th – 7th July 2006 : www.warwick.ac.uk/go/ac21
English in Higher Education in the 21st Century
6th July 2006 in the Centre for English Language Teacher Education, FME Extension, Social Studies Building,
University of Warwick, Coventry.
IMPORTANT – Unless otherwise noted, all sections must be completed. Your form will not be processed if any part is incomplete or left blank.
Section 1
This information is for your badge. Please print clearly.
Surname/family name _______________________________
First name ______________________________
Address ___________________________________________________________________________________
City ___________________________________________
Country __________________________
Phone No ___________________________________________
(area/country code)
Middle Initial _______________
This is
□
Business
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Home
Zip/Postcode _____________________
Fax Number _________________________________________________
(area/country code)
Email address ____________________________________________________________
Section 2
Registration Fees: Please tick appropriate box
Before
June 19
June 5 –
June 5 2006
2006
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Standard Rate
(£40 GBP)
(£50 GBP)
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Poster Presenter
(£20 GBP)
(£30 GBP)
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Student
(£20 GBP)
(£30 GBP)
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Warwick University staff /student or AC21 delegate
(Free)
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Warwick University staff /student wishing lunch (£5 GBP)
To register for additional AC21 Research Festival Symposia and
other events please see the following sites:
www.warwick.ac.uk/go/ac21
Registration includes refreshment breaks
throughout the symposium
As numbers are tight, if you have registered, please let us
know if you are unable to attend and we will reallocate
your space.
Registrations close June 19th. Anyone wishing to apply
after that date will be on a waiting list, and be informed
of availability as soon as possible.
http://warwick.ac.uk/go/ac21/globaled/research
Section 3
Classification: Please tick appropriate box or
boxes
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Applied Linguist
English Language Tutor
ELT Materials Writer
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Teacher Educator
Administrator
Educational Policy Maker
□ Subject tutor/lecturer
□ Early Career
□ Other
Please state ________________
Section 4
Specialities/Major Interests:
Please list top 3 interests/specialities
1.
2.
3.
Section 5
Payment:
Registration total £ _________
Please mark method of payment.
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Wire Transfer (SWIFT code NWBKGB2124V, Acc No 46348131 Sort Code 56 0045, NatWest Bank, Coventry CV1 I22)
Cheque drawn in GBP (Great British Pounds)
□ Mastercard
□ Visa
Card number ______________________________________________
Name on the card ___________________________________
Exp date ________________
Fee to be charged £ ____________
Signature ____________________________________
A full refund will be made if written notice of cancellation is
received by 5 June 2006. Partial refund will be made after
that date if we are able to fill your booking with another
paying participant.
Date _____________
We encourage participation by all individuals. If you have a disability,
notification of any special needs will help us serve you better. Check here if you
require special assistance to participate fully in the meeting.
□
Yes, attached is a written description of requirements.
AC21: 3rd Biennial International Research Festival
4th – 7th July 2006 : www.warwick.ac.uk/go/ac21