SCIFEST - Presenter Form

Name (As in Passport/SA ID Document)

Prefix (optional)

First Name

Last Name

Preferred Name (Nickname)

Passport / SA ID number

Passport: Country of Issue

Passport: Issuing Authority

Passport: Date Issued

Passport: Expiry Date

Date of Birth

Organization

Designation

Department

Email

Physical Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Postal Address (If different to Physical Address)

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Phone number (Office)

Phone number (Mobile)

Phone number (Home)

Dietary requirements

Allergies

T-shirt Size

XS S M L XL XXL

Please provide us with the contact details of the person who should be contacted in the event of an emergency.

Name - Emergency contact

Prefix (optional)

First Name

Last Name

Phone number (Office) - Emergency Contact

Phone number (Mobile) - Emergency Contact

Please provide us with the venue requirements for your presentation

List your Software Requirements (All presentations to be Windows 7/ MS Office 2010 compatible.)

Check which of the following you will require

Data Projector Laptop Laser Pointer

List any other requirements

Please provide us with your programme entry information

Title of your presentation for use in the Official Programme (Please do not use an academic title, but rather a title which will interest members of the general public)

Information about your presentation for use in the Official Programme (150 - 200 words)

Short personal biography and interesting facts about yourself for use in the Official Programme, e.g. X has a pet giraffe

Attach passport or SA Identity Document

No File Chosen

File uploads may not work on some mobile devices.

Attach a high resolution, full colour photograph (minimum 10 x 15cm at 300 dpi) of yourself .jpg or .tiff format for use in the Official Programme. We encourage lecturers to make use of photographs which are current and portray them in action (eg. abseiling), in the field

No File Chosen

File uploads may not work on some mobile devices.

SCIFEST AFRICA 2022