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Registration 5-6 July 2012

This is the online application for registration at UniQuest's Research Commercialisationⁱ workshop on 5-6 July 2012. Please review the Workshops' Terms and Conditions and UniQuest's Privacy Statement before beginning your application. Applications for this workshop will close on 15 June.

Section 1:

Personal Details

Active

Section 2:

Experience

Not Completed

Section 3:

Transport Requirements

Not Completed

Section 4:

Student/Staff

Not Completed

SECTION 1: PERSONAL DETAILS

* First name:

* Family name:

* Title:

Title - Other:

* Gender:

Male

Female

Preferred name:

* Institution:

* Staff/Student number:

* Address Line 1:

Address Line 2:

* Suburb/City:

* State:

* Postcode:

Country:

* Email:

* I agree to this email address being shared with other workshop participants:

Yes

Work phone:

* Home phone:

Mobile phone:

Send SMS updates to my mobile:

Yes please

No thanks

* Research Centre:

* Primary research interest (e.g. materials, tourism, oncology):

* Supervisor/Manager's email address:

Note: TIMS7326 and CONICYT students (only) please type m.goward@business.uq.edu.au. UTASⁱ Grad Cert Research Commercialisationⁱ students please type derek.rowlands@utas.edu.au

* My supervisor/manager supports my interest in commercialisation and is aware I am applying for this workshop:

Yes

Not Sure

* I have special requirements (e.g. dietary):

Yes

If yes, please provide details:

* I have a medical condition that UniQuest should be aware of:

Yes

If yes, please provide details:

* I require wheelchair access:

Yes

I would also like you to know the following to assist with meeting my needs at the workshop: