Academic Registration Form
I am:
Faculty  Student 
First Name: ________________________________________________________________________________
Surname: __________________________________________________________________________________
Email address: ______________________________________________________________________________
Applicant Phone Number:_____________________________________________________________________
Institution: _________________________________________________________________________________
Admissions (student) Phone number: ____________________________________________________________
Human Resources (faculty) Phone number: _______________________________________________________
Required for Student:


A valid, accredited university ID
Verifiable full‐time academic status at an accredited college or university (transcript, letter stamped
from registrar, etc)
Required for Professor:


A valid, accredited university ID
Letter from their department head on the institution's letterhead stating full‐time status.
URL (Faculty Page for Professor, if available): ___________________________________________________
Will you be providing additional form of proof will you be providing so our committee can verify your status?
If yes, please detail:

I understand that that the €450 Academic Rate applies to the Briefings only. I understand that discounted pricing
is NOT available for the training courses and that Standard Black Hat Registration Terms and Conditions apply to
this registration (http://www.blackhat.com/html/bh-eu-10/registration/bh-eu-10-registration_terms.html)
Please be as complete as possible with the information you provide. The easier it is for our review committee to verify your academic status, the quicker it will
be for us to approve your application. Completed forms may be sent to academicreg@blackhat.com or fax to 1-206-219-4143.
We will let you know if we missing any of the above information after we receive your application for a Black Hat Briefings Academic pass. Once your status has
been verified (3-5 business days) we will then send you an email notifying you of acceptance or denial and how to proceed in finalizing your registration.