Registration form

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Personal details:

Gender:
MF
Title:
Mr.Mrs.MissDr.Prof.
Family name:

First name:

Home (or work) address:

Country

Home & Cellular phone numbers:

E-mail:

Registration:

I am registering for:
The conference

Accommodation:
Please send me accommodation proposals in Tel-Aviv

Payment

Please charge my credit card in one paymentPlease divide my payments - Charge my credit card in one half of the payment now, and the second half charge only next month (the second payment will be charge 40 days after the first payment)I am paying by a Bank transfer – I'll email you the transfer details within 24 hours.

These are the bank details for the transfer:
REGINA TOURS ISRAEL LTD
BANK HAPOALIM.
GOLDA MEIR STR 801, JERUSALEM, ISRAEL
BRANCH: #538
ACCOUNT: #444770
SWIFT CODE: POALILIT
EBAN: IL340125380000000444770

VisaMaster CardAMEX
Name of Credit Card Holder:

Credit Card Number:

Expire Date:

3 back digits of Credit Card:

Remarks / Comments / requests:

The conference is being sponsored by: The University of Tel-Aviv, a world-renowned institution and Israel’s largest and most comprehensive institution of higher learning, with over 30,000 students studying across nine faculties, 29 schools and 98 departments.

The Mental Wellness Society-International whose mission is to identify, promote, and advance the acquisition of concepts and knowledge that can equip individuals with the means to achieve wellness in the psychological, behavioral, interpersonal, and physical areas of their lives.