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CONFERENCE REGISTRATION FORM

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    <h2 class="form-header" data-component="header" id="header_1" style="text-align: center;"><span style="font-size: 16px;">CONFERENCE ON DEVELOPMENT COMMUNICATION AND SOCIAL CHANGE</span></h2>

    <p style="color: rgb(0, 0, 0); text-transform: none; text-indent: 0px; letter-spacing: normal; font-family: Verdana; font-size: 12px; font-style: normal; font-weight: normal; margin-bottom: 1.3em; word-spacing: 0px; white-space: normal; background-color: rgb(255, 255, 255); font-variant-caps: normal; -moz-text-size-adjust: auto; -webkit-text-stroke-width: 0px;"><span style="color: rgb(0, 0, 255);"><span style="font-size: 14px;">There are two sections on this page that are required to be completed. The first part is&nbsp; the registration form to ascertain your attendance, and the second part is the registration fee that quarantee your participation. The form is divided into two sections because potential participants might have problems paying their registration fee online, in this case, go on with the registration and identify that registration will be paid by person. Those who have the possibility paying online should do so by completing the second part of this form.</span></span></p>

    <p style="text-align: left; color: rgb(0, 0, 0); text-transform: none; text-indent: 0px; letter-spacing: normal; font-family: Verdana; font-size: 12px; font-style: normal; font-weight: normal; margin-bottom: 1.3em; word-spacing: 0px; white-space: normal; background-color: rgb(255, 255, 255); -webkit-text-size-adjust: auto; font-variant-caps: normal; -webkit-text-stroke-width: 0px;"><span style="color: rgb(0, 0, 255);"><span style="font-size: 14px;">As we look forward seeing you, we expect that the conference will be a stimulating environment where expectations are expected to be high. Come and lets make it a success for the development of Africa</span></span></p>

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    <li class="form-line" data-type="control_fullname" id="id_3"><label class="form-label form-label-top form-label-auto" for="first_3" id="label_3">Name </label>
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    <li class="form-line" data-type="control_address" id="id_4"><label class="form-label form-label-top form-label-auto" for="input_4_addr_line1" id="label_4">Address </label>
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                <td colspan="2"><span class="form-sub-label-container" style="vertical-align: top;"><input class="form-textbox form-address-line" data-component="address_line_2" id="input_4_addr_line2" name="q4_address[addr_line2]" size="46" type="text" value="" /> <label class="form-sub-label" for="input_4_addr_line2" id="sublabel_4_addr_line2" style="min-height: 13px;"> Street Address Line 2 </label> </span></td>
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                <td width="50%"><span class="form-sub-label-container" style="vertical-align: top;"><input class="form-textbox form-address-city" data-component="city" id="input_4_city" name="q4_address[city]" size="21" type="text" value="" /> <label class="form-sub-label" for="input_4_city" id="sublabel_4_city" style="min-height: 13px;"> City </label> </span></td>
                <td><span class="form-sub-label-container" style="vertical-align: top;"><input class="form-textbox form-address-state" data-component="state" id="input_4_state" name="q4_address[state]" size="22" type="text" value="" /> <label class="form-sub-label" for="input_4_state" id="sublabel_4_state" style="min-height: 13px;"> State / Province </label> </span></td>
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                <td width="50%"><span class="form-sub-label-container" style="vertical-align: top;"><input class="form-textbox form-address-postal" data-component="zip" id="input_4_postal" name="q4_address[postal]" size="10" type="text" value="" /> <label class="form-sub-label" for="input_4_postal" id="sublabel_4_postal" style="min-height: 13px;"> Postal / Zip Code </label> </span></td>
                <td style="display: none;"><span class="form-sub-label-container" style="vertical-align: top;"><select class="form-dropdown form-address-country" data-component="country" id="input_4_country" name="q4_address[country]"><option value="">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="China">China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d&#39;Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Democratic Republic of the Congo">Democratic Republic of the Congo</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Nagorno-Karabakh">Nagorno-Karabakh</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="Netherlands Antilles">Netherlands Antilles</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Turkish Republic of Northern Cyprus">Turkish Republic of Northern Cyprus</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Palestine">Palestine</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Republic of the Congo">Republic of the Congo</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</option><option value="South Sudan">South Sudan</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard">Svalbard</option><option value="Swaziland">Swaziland</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria">Syria</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania">Tanzania</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Transnistria Pridnestrovie">Transnistria Pridnestrovie</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tristan da Cunha">Tristan da Cunha</option><option value="Tunisia">Tunisia</option><option value="Turkey">Turkey</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="Isle of Man">Isle of Man</option><option value="US Virgin Islands">US Virgin Islands</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="other">Other</option> </select> <label class="form-sub-label" for="input_4_country" id="sublabel_4_country" style="min-height: 13px;"> Country </label> </span></td>
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    <li class="form-line" data-type="control_email" id="id_5"><label class="form-label form-label-top form-label-auto" for="input_5" id="label_5">E-mail </label>
    <div class="form-input-wide jf-required" id="cid_5"><span class="form-sub-label-container" style="vertical-align: top;"><input class="form-textbox validate[Email]" data-component="email" id="input_5" name="q5_email" size="30" type="email" value="" /> <label class="form-sub-label" for="input_5" style="min-height: 13px;"> example@example.com </label> </span></div>
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    <li class="form-line" data-type="control_textarea" id="id_6"><label class="form-label form-label-top form-label-auto" for="input_6" id="label_6">Suggestions or topics you would like to be included in the conference agenda. </label>
    <div class="form-input-wide jf-required" id="cid_6"><textarea class="form-textarea" cols="40" data-component="textarea" id="input_6" name="q6_suggestionsOr" rows="6"></textarea></div>
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            <td>PAYMENT OPTIONS</td>
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        <tr>
            <td><select name="os0"><option value="Students fee including lunch">Students fee including lunch $35,00 USD</option><option value="Non-student fee including lunch">Non-student fee including lunch $75,00 USD</option><option value="Organizations">Organizations $100,00 USD</option> </select></td>
        </tr>
    </tbody>
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