Indoanesthesia 2016 REGISTRATION FORM ‘The 13° International Anoual Meeting of Indonesian Society of Obstetric Anesthesia, Indonesian Society of Regional Anesthesia and Pain Medicine ‘The 5® Indonesian Society of Critical Care Anesthesiologist February 23" - 27%, 2016, Shangri-La Hotel, Jakarta, Indonesia PARTICIPANT ( Kindly Completed ) Title Cipro SDR / Ui Dr/ O Specialist, Full name Name to Appear on Certificate Organization/Hospitalnstitution Mailing Address Country Zip Code Phone (Mobile) E-mail Sponsor oe PH REGISTRATION FEE ( Please mark (¥) on the Workshop you chooce ) WORKSHOP REGISTRATION FEE SAFE (Safe Anaesthesia From Fucation) Obstetric Anaesthesia Course ( February 23% 25%, 2016 }|| C1IDR 3.000.000,00 1 Musculoske Advance Vascullar Access ( February 24%, 2016) S Comprehensive Management of Nutrition in Perioperative and Critically Il Patients (February 24%, 2016) Winfocus Workshop ( February 24%- 25%, 2016 ) Workshop On Acute Care. Life Focused Care ( February 25*, 2016 ) 1 Perioperative Goal-Directed Therapy Update in Sepsis (February 25%, 2016 ) Regional Anesthesia Workshop: Neuraxial Block: Revisited ( February 25*, 2016 ) etal Ultrasound-Cuided Injection Workshop on Volunteer ( February 23'- 24%, 2016 }|| [1IDR 4.000.000,00 IDR 3.000.000,00 IDR 3.000.000,00 IDR 4.000.000,00 IDR 3.000.000,00 TIIDR 3.000.000,00 IDR 3.000.000,00 S Low Flow Anesthesia Workshop (February 254, 2016) Free SYMPOSIUM Before January 1" 2016 | After January 1* 2016 1 Speciale IDR 2500 000,00 GIIDR 3.000.000,00 0 General Practitioner Resident Other IDR 1.500,000,00 IDR 2.000,000,00 TOTAL Registration Workshop & Symposium IDR mall erlingpindonesa.com | gpd gpaindonesia.com Ths fom logether with the requisite payment and/or documentation shouldbe emalledined ‘he Congres Secretariat t GPD-INDONESIA.96221-7229509 [7254824 | o62 8111312 6, 9620111 662 66s | fox number 46221-7396261 PAYMENT BY ‘CANCELLATION AND REFUND POLICY (CIDR Bank Mand eens rn eoesei 86 Written cancellation notice is required. Dee Nene nana Cancellation must be received before February 1" 2016, ‘ies Dearegwe No 71a 30% refund will he returned after congress ended. cutee ene ‘No refund will he allowed thereafter. ah SecretariatIndoanesthesia 2016 ACCOMMODATION FORM The 13° International Annual Meeting of Indonesian Society of Obstetric Anesthesia, Indonesian Society of Regional Anesthesia and Pain Medicine ‘The 5® indonesian Society of Critical Care Anesthesiologist February 23°- 27%, 2016, ShangricLa Hotel, Jakarta, Indonesia PARTICIPANT ( Kindly Completed ) Title TiProf DOR 7 Ul Drs O Specialist Full name Name to Appear on Certificate Organization/Hospitalnstitution Mailing Address Country Zip Code Phone (Mobile) E-mail Sponsor ACCOMODATION RATE Please mark (7) on the Hotel you chooce Rate in Net/Room/Night include BBF Room Type | Hote Rate 1 Shangrita Hotel jakarta Deluxe Room || CIDR 1.750.000,00 Checkin Date: Checkout Date Total Night): TOTAL ACCOMMODATION PAYMENT IDR + Any changes and areas rearing room restrain precept psod ms be ene in rng te Sera atest | wk esha Abeta ppm ar mgt nl be erg «Ne how willbe app on tee ng for aye pspae synthases the a argh om ep made, IDR Bank Mandi This form, together withthe requsite payment and/or documentation shouldbe emaled/Taxed to he Congres Secretaiat at GPD-INDONESIA.+6221-7229539 | 7254424 | +62 111 332 664, #628111 662 664 | fax mumber 6221-7596261 Emil: evn gpdindonesia com | gpd gpdindonesa com