REGISTRATION FORM

Name :
( Please print name in block letters as you wish it to appear in the certificate)

IC Number :
Designation :
Organisation :
Address :
:
Tel Number : ( Office ) : H/Phone :
Email : Fax :

Meal : Vegetarian Non vegetarian Amount Paid :

Reference No :
Date :
Inquiry / Registration, please contact ;

+6016-7227068 / +6012-2361400 / +6019-7988844

Please complete the form and return via email with payment or proof of payment to ;

traumaupdatehsa@gmail.com
Pertubuhan Pembedahan Johor Bahru
Hospital Sultanah Aminah , Jalan Persiaran Abu Bakar
80100 Johor Bahru Johor
Tel : +607 2257000 ext : 3442 Fax : +607 226 1028

MODE OF PAYMENT
Registration fees does not include accomodation and travelling expenses

Bank in Direct Bank Transfer Cheque Local Order Cash

To be made payable before 16 July 2017 ( Early Birds )

Bank details
Bank Name : MAYBANK
Account Name : Pertubuhan Pembedahan Johor Bahru
Account Number : 551276074033
Please quote Johor Trauma Conference 2017 file:///D|/Trauma%20Update%202017/Trauma%20Registration%20Form.pdf

Note : All payments made are not refundable if a delegate should choose not to attend the symposium following receipt of payment. Registration
is transferable. Kindly contact us for further information
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