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Workshop on
Community-Based Rehabilitation (CBR) and Poverty Alleviation of Persons with
Disabilities |
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Participant FormPlease printout, and type or print |
| In order to enable ESCAP to facilitate administrative arrangement on your behalf, kindly complete and return this form as soon as possible to Ms Kay Nagata, Social Affairs Officer, Population and Social Integration Section, Emerging Social Issues Division, Economic and Social Commission for Asia and the Pacific, 6th Floor, United Nations Building, Rajadamnern Nok Avenue, Bangkok 10200, Thailand, fax: (66-2)288-1030 Email: <nagata @ un.org> or Ms Aiko Akiyama, Email: <akiyama @ un.org> | |
| 1. Given name: | |
| 2. Family Name: (block letters) | |
| 3. Sex: | ___ Male ___ Female |
| 4. Official Designation: | |
| 5. Contact Address: |
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| Telephone: | |
| Fax: | |
| Email: | |
| 6. Passport Details: | Nationality: |
| Date of birth: | |
| Place of birth: | |
| Passport No.: | |
| Date and place of issue: | |
| Date of Expiry: | |
| 7. Type of disability you would like to let us know | |
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Title and signature of the designating official Date |
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