First Name
As it appears in your passport

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* 1. First Name
As it appears in your passport

Last Name
As it appears in your passport

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* 2. Last Name
As it appears in your passport

How would you prefer your name to appear on a conference badge?

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* 3. How would you prefer your name to appear on a conference badge?

Email
Please double-check that there are no typos in your email address

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* 4. Email
Please double-check that there are no typos in your email address

Alternate Email

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* 5. Alternate Email

Organization

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* 6. Organization

Title

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* 7. Title

Phone (please include country code)

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* 8. Phone (please include country code)

Cell Phone (please include country code)

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* 9. Cell Phone (please include country code)

Gender

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* 10. Gender

City of residence

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* 11. City of residence

Country of residence

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* 12. Country of residence

Will you require a visa support letter to enter the USA?
If you answer YES, the GPSA will supply a tailored letter of invitation to assist with the visa application.  Participants are responsible for obtaining their own visas.

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* 13. Will you require a visa support letter to enter the USA?
If you answer YES, the GPSA will supply a tailored letter of invitation to assist with the visa application.  Participants are responsible for obtaining their own visas.

Do you have any special requirements?
Conference rooms are wheelchair accessible

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* 14. Do you have any special requirements?
Conference rooms are wheelchair accessible

Emergency Contact Information (Name and Telephone)

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* 15. Emergency Contact Information (Name and Telephone)

Is your organization a partner of the GPSA?

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* 16. Is your organization a partner of the GPSA?

Is your organization a grantee of GPSA?

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* 17. Is your organization a grantee of GPSA?

Have you attended GPSA Forum in the past?

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* 18. Have you attended GPSA Forum in the past?

Are you applying for sponsorship?
The GPSA provides limited sponsorship for participation in the Forum. Sponsored participants will be asked to play an active role in the Forum, such as speakers, rapporteurs, or moderators.  Registrations that include a request for sponsorship need to be submitted by September 7. Priority will be given to participants from developing countries.

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* 19. Are you applying for sponsorship?
The GPSA provides limited sponsorship for participation in the Forum. Sponsored participants will be asked to play an active role in the Forum, such as speakers, rapporteurs, or moderators.  Registrations that include a request for sponsorship need to be submitted by September 7. Priority will be given to participants from developing countries.

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