Ms. Mr. Mrs. Dr.
First name: ________________________________________
Last Name: _____________________________
__________________________________________________________________________________________
Title/Position: ______________________________________
Department: ____________________________
Organization: ______________________________________________________________________________
Address: __________________________________________________________________________________
City: ____________________________________________________________
Province/Territory: _________________________________________________
Country: _________________________________________________________
Postal Code: _____________________________________________________
Telephone: _______________________________
ext: _______________
Fax: ________________________
E-mail: __________________________________________________
Website: _________________________________________________
Sector:
Federal Government Provincial Government Municipal Government
Corporate Academic NGO Media Student
Other (please specify): ____________________________________________________________________
Your message: ____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Are you making a presentation? Yes
No
If yes, title of presentation:_________________________________________________
Short summary: _________________________________________________
____________________________________________________________________
____________________________________________________________________
Are you organizing a Workshop Session in your community? Yes
No
____________________________________________________________________
If yes, do you need help other than monetary help? Contact us if needed.
Describe your Worksho Session (goal, issue(s), place, participants, day and time, results, recommendations, etc.):
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Do you wish to participate in a Discussion Roundtable on Internet? Yes
No
What issue(s)?
____________________________________________________________________
____________________________________________________________________
‘Caring for Life and Earth’
