The 11 Annual Conference of Public Health Sciences

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Application Form

On Friday, September 30, 2011, at Srisuriyawong Room, Tawana Bangkok Hotel, Bangkok, Thailand ---------

Crisis in Public Health: Challenges & Solutions)

Given name(s).Surname (family name). Job title (If yes): Organization: . E-mail Address: .Phone: Fax: Mailing Address:

... If student

Students Degree Program: .

Institution:

.. Need for Oral/Poster Presentation

o Yes, I have attached Abstract electronic file with this

application form

(Please see an example of English full abstract of not more 2 pages in www.cphs.chula.ac.th ) the conference) (Applicant whose abstract is not accepted can usually attend o No

Registration Fee: 2011 After September 15 , 2011

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Before September 15 ,
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Practical Resident and Student 600 Bht. Others 800 Bht.

800 Bht. 1,000 Bht.

(10 % discount of Registration Fee for member of CPHSs academic service activities) Payment Method:

Pay in advance by wire transfer to: Siam Square Branch Workshop Account name:

Bank: The Siam Commercial Bank Public Company Limited, College of Public Health Sciences038-4-38692-4

Account number:

Signature..
2

(.) Date.//2011

Note:

Form 2) Registration Fees bank pay-in slip Oral/Poster presentation) to cphs@chula.ac.th

* Please e-mail with these attached 1) Completed Application 3) Abstract electronic file (in case you specify to propose Email address: sukarin.w@chula.ac.th, narong.c@chula.ac.th,

or fax your 1) Completed Application 0-2218-8195

** If you are only to attend the conference, you might e-mail Form 2) Registration Fees bank pay-in slip. If fax, it is at

registration fee paying at the conference is not obtainable.

*** Due to the necessity of conference advance arrangement,

very much if you would forward this

The Organizing Committee would appreciate it