Surname

First Name

Organisation

Profession/Function

E-mail Address

Postal Address

phone number (home)

phone number (office)

phone numbe (mobile)

Arrival Date

Departure Date 

Sponsor  CORAF/WECARD My Organisation Myself Other (to be specified) If other :

Accommodation at Mont Fébé Hotel : Single room Twin room Suite

Would you like to participate in the West and Central Africa Scientific Week? Yes No

If yes, do you need a booth for the exhibition of your research results and products? Yes No

Would you be interested in making a presentation on the theme or sub themes of the scientific week on proposal of organizers? Yes No

Would you be interested in and ready to chair a panel on the theme or sub themes of the scientific week? Yes No

Would you like organising a side event? Yes No

If yes on which theme?