REGISTRATION FORM Kindly fill in ALL the details required below
Transcription
REGISTRATION FORM Kindly fill in ALL the details required below
REGISTRATION FORM Kindly fill in ALL the details required below. Incomplete form would not be processed. Upon complete registration and payment, registration confirmation email will be sent to you. A. DELEGATE’S DETAILS Title: Datuk / Dato’ / Datu / Datin / Prof / Dr / Mr / Mdm / Ms Full Name as per IC/ Passport: ___________________________________________________ C/ Passport No: ______________________________________________________________ Correspondence Address: _____________________________________________________________________________________ _________________________________________________________________ Postcode: _______________ State / Country: _________________________________ Fax: ________________ Mobile No. : ______________ Email: ____________________ Special Dietary Requirement: [ ] Vegetarian [ ] Others (Please specify here: _________________________________) Profession: [ ] Allied Health Professional [ ] Doctor [ ] Pharmacist [ ] Dentist [ ] Health Inspectors [ ] Others (Please state: __________________________________________) DEPARTMENT / COUNCIL SPONSOR DETAILS Department/Unit: ____________________________________________________________ Contact Person’s Name: _______________________________________________________ Mobile Number: _____________________ Office number: __________________________ E-mail: _____________________________________________________________________ *Department / Council Sponsor details are compulsory if you are a sponsor and would like to be updated on this registration. B. REGISTRATION FEE CATEGORY DELEGATES PACKAGE (Must register by or before 30th APRIL, 2015) EARLY BIRD (Before or On 30th April 2015) STUDENT PACKAGE LOCAL INTERNATIONAL RM 980 USD 350 RM 880 USD 300 RM 800 USD 250 We accept payment using credit cards, cheque or Local Purchase Order (Please register early) *Your registration covers 2 days of conference with meals. TOTAL AMOUNT DUE: ________________________ C. PAYMENT All payment are to be issued in favor of KESATUAN INSPEKTOR KESIHATAN, JABATAN KESIHATAN SARAWAK Bank Name : MAYBANK BERHAD Bank Address : LOT 1.03, LEVEL 1, WISMA SATOK, JALAN SATOK, 93400 KUCHING, SARAWAK Account Number : 011113003338 Swift Code : MBBEMYKL Accepted payment mode : - Online Credit Card Payment - Bank-In of Cash / Cheque - Online Transfer / Telegraphic Transfer - Local Purchase Order (LPO) by Malaysian Government CONFERENCE SECRETARIAT HIUS SECRETARIAT No. 90, 1st Floor, Lot 1167, Kota Padawan, JalanPenrissen, 93250 Kuching, Sarawak. Tel: +6082 371799 / +6010 9761897 / +6016 5902135 Email: [email protected] Website: www.hius.org.my Fax: +6082 241126 An email confirmation will be sent to all confirmed delegates. Please bring it in exchange for your conference kit during the registration. CANCELLATION AND REFUND POLICY The Secretariat must be notified in writing of all cancellations. Refund will be made only after the conference and only applicable under following circumstances. Cancellations on or before 30th August 2015 : 50% Refund Cancellations after 30th August 2015 : No Refund If no refund is required but a change in participant registration is needed, then the Secretariat must be informed in writing via e-mail to [email protected] CERTIFICATE OF ATTENDANCE A certificate of attendance will be issued to all participant / delegates. CPD points will be awarded. LIABILITY The Organizing Committee will not be liable for personal accidents, loss or damage to private property of the participants during duration of the Conference. Participants should make their own personal arrangements. DISCLAIMER Whilst every attempt is made to ensure that all aspect of the conference as mentioned in this announcement will take place as scheduled , the Organizing Committee reserves the right to make last minute changes should the need arise .