Registration Form - Malaysian Participants

Life Beyond Breast Cancer
- an International Symposium
October 18 - 20, 2012
Shangri-La Hotel Kuala Lumpur, Malaysia
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PINKRIBBONR2R
REACHTO RECOVERYA'
REGISTRATION FORM
Please write in BLOCK letters and keep a photocopy of this form for your records or register online at
www.pinkribbonr2r.mv/LBBC2012
Please ensure the information submitted in this form is correct and for further
information, please visit our Symposium website.
Important registration information
•
•
•
Payment Method:
a By Chequ~1 Money Order I Bank Draft: made payable to PinkRibbonR2R Sdn Bhd and please
mail together with this completed form.
a By Bank transfer or direct bank into PinkRibbonR2R Sdn Bhd's Maybank account no.
5141 8735 5133. Please complete the form and fax with your proof of payment.
Confirmation of your registration will be sent to you within 10 working days from receipt of your registration
form and proof of payment
Registration will not be processed or confirmed until payment in full is received.
Please forward this form and cheque
I proof of payment to:
PinkRibbonR2R Sdn Bhd
Life Beyond Breast Cancer Symposium Secretariat
Unit E-10-12, 10th Floor, Amcorp Mall, Menara Melawangi, Jalan Timur, 46050 Petaling Jaya, Selangor, Malaysia
via Fax: +60379606121
or via Email: [email protected]
A. Delegate
Full Name: Mr
I Mrs I Ms I Dr I
Prof I
Last Name (Family name)
First Name (Given name)
(,pls specify)
Passport liD Number
Full Address:
Postal Code:
Country:
I
Date of Birth:
I
(dd/mmlyy)
Mobile:
Home:
Office:
Fax No.
Contact Details:
Country Code:
_
Email:
Special Dietary requirements:
Travel Details:
Emergency contact:
a Vegetarian
a Others (pis specify)
Arrival date I Flight No.:
Departure Date I Flight No.:
Full Name:
Tel: (Country Code
Fax No.:
PinkRibbonR2R Sdn Bhd (845~77-P)
Unit E-10-12, 10th Floor, Amcorp Mall, Menara Melawangi, Jalan Timur, 46050 Petaling Jaya, Selangor, Malaysia.
,Tel: +603-79606122 Fax: +603-79606121 Email: [email protected] Website: www.pinkribbonr2r.my
PINKRIBBONR2R
",ACH TO RKovm~
0
B. Accompanying Person
Full Name: Mr
Prof I
I Mrs I Ms I Dr I
Last Name (Family name)
First Name (Given name)
(pls specify)
Passport liD Number
Full Address:
Postal Code:
Country:
I
Date of Birth:
I
(dd/mmlyy)
Mobile:
Home:
Office:
Fax No.
Contact Details:
Country Code:
_
Email:
Special Dietary requirements:
Travel Details:
Emergency contact:
o Vegetarian
0 Others (pis specify)
Arrival date I Flight No.:
Departure Date I Flight No.:
Full Name:
Tel: (Country Code
FaxNo.:
C. Registration Fees (per delegate-! accompanying person)
Early Bird Full Registration
(By 30 June 2012)
Regular Full Registration
(1 Jul 2012 - 31 Aug 2012)
RM600
RM 750,
Accompanying
Person Registration
RM400
•
Registration in advance is required for Symposium participation. All registration forms must be received by
the Secretariat before 31 Aug 2012. Registration closes on 31 AUQ 2012 and there will be no on-site
registration.
•
Full registration covers the opening and closing ceremony, all conference sessions and exhibition, coffee
breaks, lunches, welcome reception, gala dinner, conference kits and a city tour.
•
Accompanying person's registration covers welcome reception, opening and closing ceremony, exhibition,
gala dinner and a city tour. The city tour route arranged for the accompanying person will be the same as
the main registrant.
PinkRibbonR2R Sdn Bhd (845977-P)
Unit E-10-12, 10th Floor, Amcorp Mall, Menara Melawangi, Jalan Timur, 46050 Petaling Jaya, Selangor, Malaysia.
Tel: +603-79606122
Fax: +603-79606121
Email: [email protected]
Website:www.pinkribbonr2r_my
PINKRIBBONR2R
ReACHTO RKoveRYA'
0
D. Payment and conditions
RM
1
Delegate Registration Fee
2
Accompanying
3
Additional Gala Dinner Ticket (
person/s (
RM
pax x RM 400)
RM
pax x RM 300)
RM
TOTAL FEES ENCLOSED
Payment Method:
o
Cheque No. I Mail Order No. I Bank Draft No.
o
Bank Transfer I Direct Bank into PinkRibbonR2R Sdn Bhd's Maybank account no.: 5141 87355133
(,made payable to PinkRibbonR2R
Sdn Bhd)
E. Complimentary City Tour
•
Please number your preference starting with 1 for most preferred route and please refer to the Symposium
website on City Tour for more information .
•
Delegates may be requested to take route for city tour that they have indicated as their second or third
preference due to the maximum number of participants each route can accommodate.
D
Route 1: Putrajaya Tour
D
Route 2: KL City Tour
D
Route 3: KLCC walking tour
I have read and agreed to all the terms and conditions outlined in this registration form and the Symposium
website www.pinkribbonr2r.mv/LBBC2012
'
Signature
-------------
Date:
1
1
PinkRibbonR2R Sdn Bhd (845977-P)
Unit E-10-12, 10th Floor, Amcorp Mall, Menara Melawangi, Jalan Timur, 46050 Petaling Jaya, Selangor, Malaysia.
Tel: +603-79606122 Fax: +603-79606121 Email: [email protected] Website: www.pinkribbonr2r.my
_