12th ICT4D Conference Passcode Registration Form 2020 Passcode Registration Form Step 1 of 6 16% Enter your Passcode* You must enter a valid Passcode to continue with registration. Ticket SelectionType of Organization*For-profit - StandardFor-profit - Low/Lower-Middle Income Country DiscountNon-profit, Government, Academia, SME, Entrepreneur - StandardNon-profit, Government, Academia, SME, Entrepreneur - Low/Lower Middle-Income Country DiscountCatholic Relief ServicesMedia/PressMedia/Press Confirmation* I confirm that I am a member of the Media/Press. Media/Press passes guidelines for the ICT4D Conference: - Only credentialed members of the press qualify for a complimentary registration - Must have an editorial title (titles accepted: publisher, editor, staff writer, reporter, columnist, journalist, photographer, broadcasters and web bloggers associated with the conference subject area). - Work in nationally or regionally recognized publications or press outlet with a technology, finance, health, agriculture, education, government, NGO, international development or humanitarian response readership - Will be required to produce accreditation in the form of a photocopy of a recognized press or media card, business card, a letter from the editor or an official web address linking to a press release in order to verify their position For-profit, Low/Lower-Middle Income Country Discount Registration* Proceed with For-profit, Low/Lower-Middle Income Country Discount Registration If you wish to register with the For-profit, Low/Lower-Middle Income Country Discount Registration, please refer to the official World Bank website (http://data.worldbank.org/?locations=XN-XM) for a list of countries that qualify. Only those organizations founded and headquartered in a Low/Lower middle-income country are eligible for those rates. International businesses and iNGOs are excluded from those rates regardless of their location.Non-profit & Government, Low/Lower-Middle Income Country Discount Registration* Proceed with Non-profit & Government, Low/Lower-Middle Income Country Discount Registration If you wish to register with the Non-profit & Government Low/Lower Middle-Income Country Discount Registration, please refer to the official World Bank website (http://data.worldbank.org/?locations=XN-XM) for a list of countries that qualify. Only those organizations that are founded and headquartered in a Low/Lower-middle Income country are eligible for those rates. International businesses and iNGOs are excluded from those rates regardless of their location. Entrepreneurs/ Startups/ Small Medium Enterprises/ Independent Consultants (less than 5 employees), Not-for-Profit: Please be prepared to submit proof of non-profit status.Non-profit, Government, Academia, SME, Entrepreneur - Standard Registration* Proceed with Non-profit, Government, Academia, SME, Entrepreneur - Standard Registration Entrepreneurs/ Startups/ Small Medium Enterprises/ Independent Consultants (less than 5 employees), Not-for-Profit: Please be prepared to submit proof of non-profit statusNumber of Days Attending:*Full Conference (3 Days)2 Days1 DayDay Attending* Tuesday, April 21, 2020 Wednesday, April 22, 2020 Thursday, April 23, 2020 Days Attending Tuesday, April 21 and Wednesday, April 22, 2020 Wednesday, April 22 and Thursday, April 23, 2020 Tuesday, April 21 and Thursday, April 23, 2020 Organization InformationOrganization Type*Government AgencyMulti-lateralPrivate BusinessSocial EnterpriseEducational InstitutionResearch InstitutionINGOLocal NGOFoundationMedia/PressOrganization Name* Organzation Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website* Attendee's InformationIf you are filling out this form for someone else, please note that the information below is for the person attending the conference.Full name (for conference name badge and networking only)* First Last Full name as shown on your passport (for the Visa Support Letter)* First Last Email Address* Enter Email Confirm Email Please enter a valid professional email that we can use to keep you informed of the ICT4D Conference and related developments. If you are applying on behalf of a colleague please ensure you insert his/her email address here.Phone*Twitter Blog Country Where You Are Currently Based*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountry of Which You Are A Citizen*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweWill you require a Visa Support Letter to apply for a Nigerian visa?* Yes No For information on a Nigerian visa, visit https://immigration.gov.ngProvide your Passport No.* The information provided will populate your Visa Support Letter. Your personal data will not be shared with external organizations and deleted after 6 months of collecting. Attendee's InformationAttendee's Job Title* Attendee's Job Category*Technical SpecialistProgram ManagerExecutiveOther (specify)Please specify Attendee's Area of Specialization*AgricultureEducationEmergency Preparedness/Response/RecoveryEnvironmental ProtectionFinanceGeneral ManagementHealth & NutritionITMicrofinanceMonitoring and EvaluationProject ManagementWater and SanitationOther (specify)Please specify Sectors of Greatest Interest (Check all that apply)* Agriculture ICT Humanitarian Response and Resilience Education & Digital Literacy Environmental Protection Digital Financial Inclusion Wash Security (WASH & WASH Resource Management) Health & Nutrition Infrastructure Livelihoods Data Strategy/Data Privacy Supply Chain Digital Diversity Responsible Data & Information Security Other (specify) Please specify Technology/Data Centric Themes of Greatest Interest (check all that apply)* 3D Printing 5G Analytics Artificial Intelligence/Machine Learning Augmented Reality/Virtual Reality Big Data Biometrics Blockchain Cloud Computing Connectivity Digital Identity Digital Services Drones/UAVs GIS/Mapping Internet of Things Mobile Devices Open Data Power Principles for Digital Development Privacy and Data Protection Remote Sensing Satellite Imagery Smart Systems Social Media User-centric Design Visualization Other (specify) Please specify Have you been selected to speak at the 12th ICT4D Conference?*YesNoPlease note, if you have applied to speak, we will send you a notification email in January 2020. Select 'No' until you receive a notification email from the Organizing Team.Please provide your Speaker ID no. Your 4 digit Speaker ID no. can be found on the notification email you received confirming you have been offered a speaking slot. Do not leave any blank spaces. Do you have any food allergies or special dietary requirements? In case of emergency, please contact Emergency Contact telephone Data Protection and Privacy* I consent I do not consent We would really like to continue sending you the latest updates, information, and invitations to the ICT4D Conference and other events, initiatives and activities. In order for us to be able to do this, we need you to give us permission. To do this, please select the 'I Consent' button below. If you do this, we will be able to keep you on our mailing list. You can still unsubscribe at any time, by clicking on the unsubscribe link at the bottom of our emails. Please see the main website for more details of our Data Protection Policy: https://www.ict4dconference.org/privacy-policy/By submitting this application, I agree that:*My contact information will be safeguarded by the ICT4D Conference as identified in the ICT4D Conference Privacy Policy www.ict4dconference.org/privacy-policy My full name, job title and organizational affiliation will be uploaded and be visible to other attendees on the conference agenda website https://ict4dconference.pathable.com. Conference attendees are sent an invitation to login, complete an online profile, preregister for agenda sessions and have the ability to privately message as well as schedule meetings with other event attendees The ICT4D Conference fee is not refundable after February 20, 2020. Cancellations must be received in writing before this date to admin@ict4dconference.org After the conference cancellation deadline date, no refunds can be made; however, the registration fee can be transferred to a substitute attendee from the same organization. To make a substitution, notify ICT4D Conference with the substitute’s email address, full name as it appears on the passport, passport number, full name they would like on their conference badge, job title, the country they are travelling from, nationality and address and who is being replaced; their full name, email address and job title to admin@ict4dconference.org If the ICT4D Conference is obliged to cancel the event for whatever reason, then I will receive a full refund of all attendee fees already paid, less any PayPal administrative fees if applicable. The ICT4D Conference is not liable for any travel, visa or accommodation expenses incurred by me or my organization if the event is cancelled or postponed. I am responsible for arranging any travel insurance that may be required. My travel insurance may cover cancellation costs At the event I am likely visit one or more exhibitors on their stand or attend one or more sessions. By allowing my badge to be scanned by an exhibitor, or at a session door, the exhibitor or session sponsor will have access to my name and contact information provided during this registration process for them to follow up post event. For contact details not to be passed on, please refrain from having your badge scanned by exhibitors or at session entrances. Badges will be scanned at the main entrance to the event upon arrival, this badge scan is for analytical purposes only and no data is transferred to any other parties. I consent to filming and photography of the event and the ICT4D Conference to use any such recording or photography for educational, promotional, marketing and other purposes I understand that circumstances beyond the control of the ICT4D Conference may necessitate substitutions, alterations or cancellations of a speaker and/or program topic I will abide by the ICT4D Conference rules code of conduct and the event host venue’s non-smoking and security policies. For full Terms & Conditions, visit www.ict4dconference.org/terms-conditions I agree to all the above terms Due to technical difficulties this page cannot be displayed. Please use your browser’s “Back” button to return to the previous page.