Come join us for an unforgettable experience! - Malaysian Dental ...
Come join us for an unforgettable experience! - Malaysian Dental ...
Come join us for an unforgettable experience! - Malaysian Dental ...
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35th<br />
ASIA PACIFIC DENTAL CONGRESS<br />
REGISTRATION FORM<br />
Venue: Kuala Lumpur Convention Centre,<br />
Kuala Lumpur, Malaysia<br />
Date: 7 - 12 May 2013<br />
PARTICIPANT<br />
Title: please indicate Professor Dato Datin Dr Mr Mrs Ms<br />
MDC No..____________________( applicable to Malaysi<strong>an</strong> only)<br />
DCR No.___________________ ( applicable to Singapore<strong>an</strong> only)<br />
Name:__________________________________________________________________________________________________________________<br />
(in BLOCK LETTERS <strong>an</strong>d as appears on your Identity Card)<br />
Institution: ___________________________________________________________ Department:________________________________________<br />
Address:________________________________________________________________________________________________________________<br />
______________________________Postal code:______________________ State: _________________ Country:__________________________<br />
Tel no:___________________ Fax no:___________________ Mobile:__________________ E-mail:_____________________________________<br />
Special diet: Vegetari<strong>an</strong> Others. Please specify:___________________________________________________________________________<br />
REGISTRATION FEES FOR LOCAL DELEGATES<br />
Please indicate your registration <br />
1st December 2011<br />
- 31st December 2012<br />
RM600.00<br />
1st J<strong>an</strong>uary 2013<br />
- 30th April 2013<br />
RM700.00<br />
On-site registration<br />
RM800.00<br />
TOTAL (A): RM ______________________<br />
REGISTRATION FEES FOR FOREIGN DELEGATES<br />
Please indicate your registration <br />
Particip<strong>an</strong>ts<br />
DENTIST (FROM APDF MEMBER COUNTRIES)<br />
DENTIST (NON-MEMBER COUNTRIES)<br />
DENTAL HYGIENIST, DENTAL NURSE & DENTAL TECHNICIAN<br />
UNDERGRADUATE DENTAL STUDENT<br />
ACCOMPANYING PERSON<br />
Early Registration:<br />
Up To<br />
December 2012<br />
USD 350<br />
USD 400<br />
USD 100<br />
USD 100<br />
USD 100<br />
On-site registration<br />
USD450<br />
USD 500<br />
USD 200<br />
USD 200<br />
USD 200<br />
TOTAL (B): RM ______________________<br />
STUDENT CERTIFICATION<br />
I certify that _______________________________________________is a full time undergraduate dental student.<br />
Name of Institution:________________________________________________ Head of Department:____________________________________<br />
Authorized Signature:_______________________ Official Stamp_________________________________ Date:___________________________
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