REGISTRATION FORM

The 5th Live Surgery Of Artroscopy ACL Reconstruction Workhop

February 26 27, 2016
Royal Sports Medicine Centre Royal Progress Hospital, Jakarta

Please fill in this form with capital letters.

NAME

: ...............................................................................................................

INSTITUTION

: ...............................................................................................................

ADDRESS

: ...............................................................................................................
...............................................................................................................
...............................................................................................................

PHONE NUMBER

: ...............................................................................................................

FAX NUMBER

: ...............................................................................................................

EMAIL

: ...............................................................................................................

PAYMENT METHODS
Account Name

: PT. TRI RAGA UPAYA EKA

Account Number

: 167 00 0127 6327

Bank

: Bank Mandiri

Bank charge will be borne by participants.

REGISTRATION FEE
Member Of IOSSMA

Non-Member

WORKSHOP

IDR 3.750.000

IDR 5.000.000

EHANDS-ON
(Only for 20 participant)

IDR 9.000.000

IDR 12.000.000

OBSERVER
(Only for 10 participant)

IDR 6.750.000

IDR 9.000.000

DRY LAB
(Only for 10 participant)

IDR 2.250.000

IDR 3.000.000

RESIDENT

IDR 1.000.000

PLEASE FAX OR EMAIL THIS FORM TO SECRETARIAT

FAX: +62 21 3901217, EMAIL: truemiceorganizer@gmail.com

TRUE MICE ORGANIZER

Gd. Permata Cikini Lt.2
Jl. Pegangsaan Timur No.7, Menteng
Jakarta Pusat
Contact Person: Vivid 0813 1017 9881