Name:  ______________________________________________     Date of Birth: _______________  
Passport Number: ______________________________________
Title or Position:________________________________________
Agency/Organization: ___________________________________
Office Mailing Address: __________________________________
E-mail Address:________________________________________
Office Telephone: ______________________________________
Fax Telephone: ________________________________________
Home Telephone (for emergencies):_________________________

Hotel Accommodations - Single _____;  Double _____;  Roommate _______
Arrival Date: ______________________ Departure Date: ______________________

Do you require any special services? (Please explain your needs)
•Dietary concerns and restrictions

•Special room accommodations due to a disability or impairment

PAYMENT METHOD
Visa _____ Mastercard _____
Name as it appears on the card: ___________________________________________________
Credit Card Number: _____________________________________________________________
Expiration Date: ________________________________________________________________

For payment by Wire transfer, the workshop registration fee (plus the wire transfer cost) comes to US  $2,825; also the following information must be provided to your bank:

(1) Bank: Treasury NYC
(2) City: New York City
(3) ABA: 021030004
(4) ALC: 14060905
(5) Reference: International Canal Operation and Control Workshop, A1R-1465-0004-003-00-0-0(9)