Registration Form

Registration Form On-the-Spot Poetry Writing Contest Entry Number_______________ FULL PRINTED NAME__________________________________________________ Address _______________________________________________________ _______________________________________________________ Age ____________ Birth Date _______________________ (Month, Date, Year) Contact Number Tel. No. (if any) ______________ Mobile No. (if any) ____________ Email Address: ____________________ If a student: Year Level___________________ School _______________________________________________________ School Address _______________________________________________________ _______________________________________________________ If a member of the organization of victims’ families: Organization _______________________________________________________ Address _______________________________________________________ ______________________________________________________

__________________________________________ Signature over printed name of contestant Please fax, email or send not later than December 4, 2009 to:

Asian Federation Against Involuntary Disappearances Rms. 310-311 Philippine Social Science Center Building Commonwealth Avenue, Diliman, 1103 Quezon City Philippines Telefax 00-632-4546759 Telephone Number 00-632-9274594 Mobile 00-63-9177924058 Email [email protected] website www.afad-online.org