ICLC 6.0 ON-LINE REGISTRATION FORM
ICLC 6.0 EN LIGNE FORMULAIRE D'INSCRIPTION
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S.W.A.T. Leadership Academy
Surname *
Nom de famille
First Name *
Prénom
Other Name
Autre nom
Church / Region *
Eglise
Gender *
sexe
Status *
Statut
Category *
Catégorie
Country *
Patrie
State of Origin
Seulement Nigérians
School
École
Course of Study
Cours d'études
Phone Number / Numéro de téléphone *
e.g: +234 809 9873 245
E-mail Address *
Adresse e-mail
DO YOU HAVE ANY ALEGIES OR MEDICAL CONDITION? (If yes, please be specific):
Avez-vous une ALEGIES OU CONDITION MÉDICALE? (Si oui, s'il vous plaît soyez précis):
Bank Name / Nom de la banque: Zenith Bank
Account Name / Nom du compte: ICOC S.W.A.T ACADEMY
Account Number / Numéro de compte: 1013691454
Payments details for PARTICIPANTS WITH MEMBERSHIP IN LAGOS:
27st  December – 31st May 2014 ……………………N 15,000
1st June 2014 – 30th June 2014……………………….N 20,000
1st July 2014 – 31th July 2014……………..………….N 25,000

Payments details for PARTICIPANTS WITH MEMBERSHIP OUTSIDE LAGOS AND NIGERIA:
27st  December – 31st May 2014 ……………………N 10,000
1st June 2014 – 30th June 2014……………………….N 15,000
1st July 2014 – 31th July 2014……………..………….N 20,000

Category Of Payment / Catégorie De Paiement *
Group Payment: Each Member of the Group registers Separately / Groupe Paiement: Chaque membre du groupe inscrit séparément
Teller Number[s] *
Nombre de Teller
Amount Paid *
Montant Payé
Would you require pre-conference accommodation? / Souhaitez-vous besoin d'un logement pré-conférence?
Available to participants outside Lagos Only / Disposition des participants en dehors de Lagos Seulement
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