EVENT REGISTRATION FORM (LISTENER)

World Research Forum

Payment of a registration fee covers the cost to attend all conference activities, coffee breaks, conference reception and banquet, and all lunches
during the conference. In addition, each registrant will receive a copy of the conference proceedings with ISBN. Notice that this registration fee does
not cover transportation fee, accommodation fee, and after conference tour fee.

Please complete this form and email a scanned copy to:

info@wrfconference.com

Event Name International Conference on Health and Medicine (ICHM-19)

Venue/Place of Event Hyatt Regency Hotel, Sha Tin, Hong Kong
Date of Event 14th – 16th March, 2019

PLEASE KINDLY FILL IN A SEPARATE REGISTRATION FORM FOR EACH CONFERENCE PARTICIPANT
Name: Nugroho Adiwarso Qualification Obstetric & Gynecology Specialist

Affiliation Independent

Mailing Address Jalan Rajawali 23 RT 06/RW 04, Kelurahan Tempelan, Kecamatan Blora,

City, Zip, Country Kabupaten Blora, 58211, Indonesia

Mobile 08122706635 Email elynug.garisoval@gmail.com

Delegate’s Info Reg. ID:

Total number of
No of Conf. attend More than 10 2
publication(If any)

PAYMENT Details

Total Amount (USD) Bank Name Remitter Date Ref. No

At coast For online transfer

(Debt card/Credit card/Online Banking)
Order ID/Traction ID:

Note: It is mandatory to provide a scan copy of ID Proof along with this Registration form

ADDITIONAL INFORMATION
 Will you present physically at the event_________Yes___________________(Y/N).

 No. of Persons attending the event with you? (Including your Co-authors)___4___.

 Will your Guide/HOD/Principal attending will attend the Event? ___Yes______(Y/N).

Declaration & Undertaking Photo Here

1. I have not published this paper anywhere before.
2. I will not cause or involve in any sort of violence or disturbance within and Outside of the Conference/Event
Venue.
3. WRF has all rights reserved to shift the venue, rescheduling the date of the Event.
4. I do here by declare that all the information given by me is true and if at any moment it is found to be wrong
my registration for event will be cancelled by WRF and take necessary action against me.
5. I am transferring the Copyright of my paper to WRF.

Signature:-____________ Date:- 2019/02/12

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