TUNISIA-LIBYA INFRASTRUCTURE INVESTMENT FORUM

DJERBA, TUNISIA - 18-19 Feb. 2012

REGISTRATION FORM
Tunisia-Libya Infrastructure Investment Forum is by invitation only, reserved to top level executives. In order to secure your registration, please fill out this form and send it via e-mail to sbm@smadja.ch Fields marked with a * are mandatory

Personal Information
Title * Last Name * First Name * Company/Organisation Position * Telephone
(incl. country code)

Direct Fax
(incl. country code)

Direct Phone *
(incl. country code)

Cell Phone
(incl. country code)

Email *

Company Information
Company Name Sector * Address * City * State Website Assistant Name Assistant Phone Assistant Email ZIP * Country *

Documentation
In order to complete registration, please send to sbm@smadja.ch 1 electronic photograph of yourself (Bitmap [.bmp] or Jpeg [.jpg] format). These will be used on badges for identification purposes 1 personal biography (120 words maximum) 1 company profile (90 words maximum)
Note: Registration cannot be confirmed until all required materials mentioned above are received and payment completed Due to a limited seated capacity of 100 participants, your payment has to be made within 7 days after registration to secure your participation

Registration Fee
The registration fee is USD 650 ( FOR CONECT MEMBERS ONLY ) This fee covers all activities mentioned in the program
Travel and accommodation are not covered by the registration fee and need to be organized separately (see "Venue & Accomodation" section below)

Cancellation policy
Should you need to cancel your participation, you may nominate a replacement. The nominee must be of senior executive level and the substitution will be subject to approval by the organizing committee. In the event of a cancellation made prior to: Until January 17th, 2011 -> 50% of the registration fee will be refunded After January 17th, 2011 -> No refunds will be made for cancellations Cancellations have to be notified in writing and sent by e-mail to sbm@smadja.ch

Payment
Credit Card Credit Card Type
(Visa, Mastercard, Amex)

Bank Transfer Account number 000000787902006 122100024 CHASUS33

Name On Card Card Number Security code Expiration

OR

ABA/Routing Swift Code

Venue & Accomodation

The Tunisia-Libya Infrastructure Investment Forum will take place in Djerba, Tunisia. Details of the venue and preferential room rate will be given upon registration.
Safe Harbor Global
3924 18th Street NE, Washington D.C., 20018, USA info@safeharbor.com Tel. +1 (202) 549-3399 - info@safeharbor.com

CONECT
13, rue Mohamed Abdou, Mutuelle ville, Tunis 1082, Tunisia contact@conect.org.tn Tel. +216 71 289 670 - contact@conect.org.tn