1st Rotaract District Conference 2011
Rotary International District 3272
23rd and 24th April 2011
Hosted by: Rotaract Club of Lahore Model Town
Registration Form
_______________________
Registration Number
(for office use only)
Please Tick one
Rotaractor
Guest
Rotarian
Interactor
Invited By (For guests only)
Inner Wheel Member
Personal Information
Full Name
(First)
(Middle)
Call Name
Club
Year of Joining
Rotaract/Rotary Position
Address
Membership #
Mobile#
Office#
Res#
Email
(Last)
Classification
Emergency Contact
Name
Contact Number 1
Relationship
Contact Number 2
______________________
______- _____ - 20___
Signature
( DD - MM- YYYY)
Amount Received Rs. _______________________ Received By: ________________________
Registration Rates
Rotaractor
Rotarian
Inner Wheel
Interactor
Guest
At DISCON 2010 (Till
1st May 2010)
2nd May 2010 to 31st
December 2010
1st January 2011 to
1st March 2011
1st March 2011
Onwards
2000
2500
2000
1500
2500
2500
3000
2500
2000
3000
3000
3500
3000
2500
3500
3500
4000
3500
3000
4000
Please Send your Registration Form and Remittances to:
District Secretariat
Rtr. Natash Ali Mian
District Rotaract Representative
Address: 34-D, HBFC Ichhra Apartments,
Rasool Park, Shama Road, Lahore.
Residence: 042-37501396
Cell: 0321-9464209
Email: natash_mian@yahoo.com
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District Conference Secretariat
Rtr. Fazal Habib
Conference Chairman
Address: 27-C Zahoor Elahi Road
Gulberg II, Lahore.
Residence: 042-35757902
Cell: 0321- 9479864
Email: fazalhabib@gmail.com
Important
Registration will be confirmed after receiving full payment and registration form.
For on spot registration, Conference Kit will be given subject to availability.
All payments to be made in form of Pay order/ Demand Draft/ Cash.
All Payments should be made in favor of “Rotaract Dist 3272”.
Please fill the form in Block Letters.