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, Social Studies Building, University of
Warwick
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
□
Home
Zip/Postcode _____________________
Fax Number _________________________________________________
(area/country code)
Email address ____________________________________________________________
Section 2
Registration Fees: Please tick appropriate box
Before
June 5 2006
□
□
□
After
June 5 2006
Registration fee includes refreshment breaks
throughout the symposium
Standard Rate
(£40 GBP)
(£50 GBP)
Student or Poster Presenter (£20 GBP)
(£30 GBP)
Warwick University staff /student or AC21 delegate
To register for additional AC21 Research Festival Symposia and other events
please see the following sites:
www.warwick.ac.uk/go/ac21
http://www2.warwick.ac.uk/newsandevents/events/ac21/globaled/research/
Section 3
Classification: Please tick appropriate box or boxes
□
□
□
Applied Linguist
English Language Tutor
ELT Materials Writer
□
□
□
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.
□
□
□
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 refund will be made if written notice of cancellation is received by 5
June 2006
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.