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 □ 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 □ Standard Rate (£40 GBP) (£50 GBP) □ Poster Presenter (£20 GBP) (£30 GBP) □ Student (£20 GBP) (£30 GBP) □ Warwick University staff /student or AC21 delegate (Free) □ 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 □ □ □ 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 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