Application for Urban Leadership Course

• Please provide the following contact information:

  Name
  Title
  Organization
  Address
  City
  Country
  Work Phone
  FAX
  E-mail
  URL

• Please identify and describe yourself:

  Name
  Date of Birth
  Sex	Male Female

• Please describe your role in the city and reason for taking this course:

• Please give one other city leader in your city who can act as a reference for you:

             Referees Name & Role:    

             Referees email:  

• What is your preferred times of web meeting ? (we have suggested Wednesdays,
  New Zealand time(GMT +12):

• Enter the date of registration: -- dd/mm/yy