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  • 10thMHCongress RegForm

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    This document is a registration form for the 10th Malaysian Hospice Congress taking place from June 1-3, 2012 in Johor Bahru, Malaysia. It requests information such as name, institution, contact details, and selections for symposiums and workshops. There are different registration fees for doctors, nurses/volunteers, and others. Payment can be made by cheque or bank draft to the Palliative Care Association of Johor Bahru. The completed form and payment are due by March 31, 2012.

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    This document is a registration form for the 10th Malaysian Hospice Congress taking place from June 1-3, 2012 in Johor Bahru, Malaysia. It requests information such as name, institution, contact details, and selections for symposiums and workshops. There are different registration fees for doctors, nurses/volunteers, and others. Payment can be made by cheque or bank draft to the Palliative Care Association of Johor Bahru. The completed form and payment are due by March 31, 2012.

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    6 views1 page

    10thMHCongress RegForm

    Uploaded by

    malaysianhospicecouncil6240
    This document is a registration form for the 10th Malaysian Hospice Congress taking place from June 1-3, 2012 in Johor Bahru, Malaysia. It requests information such as name, institution, contact details, and selections for symposiums and workshops. There are different registration fees for doctors, nurses/volunteers, and others. Payment can be made by cheque or bank draft to the Palliative Care Association of Johor Bahru. The completed form and payment are due by March 31, 2012.

    Copyright:

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    REGISTRATION FORM

    10th MALAYSIAN HOSPICE CONGRESS

    Palliative Care "Meeting the Increasing Needs"


    The Puteri Pacific Hotel, Johor Bahru, 1-3 June 2012 Dato/Dr/Mr/Mrs/Ms (in BLOCK Letters): Institution: Mailing Address: Post Code Tel.Office: Email: (YES) (NO) (YES) (NO) Attending the Congress Banquet (Saturday, 2nd June 2012 @ 7.30pm) Request for vegetarian food servings Fax: Tel.Mobile:

    Select only one: 2:00 - 3:30 pm 4.00 - 5:00 pm Select only one: 11:15 - 12:30 pm 02:15 - 3:30 pm 04:00 - 4:30 pm 9:00 - 10:30 am 11:00 - 1:00 pm SYMPOSIUM - 2nd June 2012 Symposium 1 Symposium 2 Symposium 4 Symposium 5 Symposium 7 Symposium 8 SYMPOSIUM - 3rd June 2012 Symposium 9 Symposium 10 Symposium 12 Symposium 13 Symposium 3 Symposium 6 Free Papers Symposium 11 PRE-CONGRESS WORKSHOP - 1st June 2012 Workshop 1 Workshop 2 Workshop 4 Workshop 5 Workshop 3 Workshop 6

    REGISTRATION FEE
    DOCTORS NURSES/VOLUNTEERS OTHERS 1 W/shop RM70.00 RM50.00 RM50.00 2 W/shop RM100.00 RM 80.00 RM 80.00 Full Regn. RM300.00 RM250.00 RM250.00 This includes full admission to the congress, lunch,congress banquet and tea breaks

    Method of payments: Cheque/Bank draft/Government Local Purchase Order (LPO) Please make payment in favour of "PALLIATIVE CARE ASSOCIATION OF JOHOR BAHRU" Bank: Cheque No: LPO Reference No: Amount:

    Please send the completed form and payment by 31 March 2012 to: The Secretariat, 10th Malaysian Hospice Congress 44, Jalan Tun Abdul Razak, Susur 1, 80000 Johor Bahru

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