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First Name:

Last Name:

Name on Call / Badge:

Rotary / Rotaract / Interact Club:

Classification:

Position in Rotary / Rotaract / Interact:

Paul Harris Award (mark as appropriate):
Yes
No
Multiple-Major
Please make a selection.

Email Address:

Phone:

Fax:

Address (P.O. Box - Code):

City:

Country:
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Kindly indicate the number of other persons in your group if its a shared room. In this case, will be paying the conference registration fees.

Arrival Date:

Departure Date:

Arrival in Mombasa by:
N/A Air Air(with transfer) Road

Flight Number:

Registration Type:
Registration Only Registration including Accommodation

I warrant that the above information is true, accurate and complete. I agree to the terms and conditions of the hotels and the booking and registration requirements of the Rotaract Disctrict 9200. I confirm that having understood the service provided by the Registration Committee,