Endobronchial Ultrasound Course 2013 - Singapore General Hospital
Endobronchial Ultrasound Course 2013 - Singapore General Hospital
Endobronchial Ultrasound Course 2013 - Singapore General Hospital
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Registration Form<br />
ENDOBRONCHIAL ULTRASOUND COURSE <strong>2013</strong><br />
1—2 February <strong>2013</strong>, <strong>Singapore</strong><br />
Secretariat<br />
SGH Postgraduate Medical Institute<br />
Block 6 Level 1, Outram Road <strong>Singapore</strong> 169608<br />
Tel: (65) 6321 4071 Fax: (65) 6223 9789 Email: pgmi.courses@sgh.com.sg<br />
Attention: Ms Jessica Leong<br />
PARTICULARS<br />
(Please tick accordingly)<br />
Prof A/Prof Dr Mr Ms<br />
Family Name _____________________________ Full Name ____________________________________<br />
Mailing Address __________________________________________________________________________<br />
__________________________________________________________ Postal Code ( )<br />
Country _________________________________ MCR No (for local doctors only) ___________________<br />
Email ___________________________________________________________________________________<br />
Contact Tel no ______________________________ Facsimile ____________________________________<br />
COURSE FEE : SGD 500 (inclusive of GST)<br />
MAXIMUM PARTICIPANTS : 20<br />
PAYMENT<br />
( ) Enclosed cheque no: __________________ bank: _____________ for S$ __________ being payment of registration fee.<br />
Cheque should be made payable to: “<strong>Singapore</strong> <strong>General</strong> <strong>Hospital</strong> Pte Ltd”.<br />
( ) Payment via Telegraphic Transfer (All bank charges will be borne by the delegate. In the event, if there is a shortfall of<br />
payment received, the secretariat will collect the balance payment.)<br />
CANCELLATION/REFUND<br />
Bank details as follows:<br />
Name of Account: <strong>Singapore</strong> <strong>General</strong> <strong>Hospital</strong><br />
Bank Account No: 032-001600-6<br />
Bank Name: DBS Bank Ltd<br />
Great World City Branch, 1 Kim Seng Road, #02-02 <strong>Singapore</strong> 237994<br />
Bank code: 7171 Branch code: 032 Swiftcode: DBSSGSGXXX<br />
Please quote: EBUS <strong>2013</strong><br />
Any cancellation or replacement must be conveyed to the Organiser in writing. A cancellation fee of 50% registration fee will be charged if<br />
the cancellation is received after 29 January <strong>2013</strong>.<br />
Secretariat<br />
Tel: (65) 63214071<br />
Fax: (65) 6223 9789<br />
Email: pgmi.courses@sgh.com.sg<br />
SGH Postgraduate Medical Institute<br />
<strong>Singapore</strong> <strong>General</strong> <strong>Hospital</strong><br />
Block 6 Level 1, Outram Road<br />
<strong>Singapore</strong> 169608