01.01.2013 Views

Endobronchial Ultrasound Course 2013 - Singapore General Hospital

Endobronchial Ultrasound Course 2013 - Singapore General Hospital

Endobronchial Ultrasound Course 2013 - Singapore General Hospital

SHOW MORE
SHOW LESS

You also want an ePaper? Increase the reach of your titles

YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.

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

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!