12 TH IMSPQ 2014 REGISTRATION FORM

Please complete the form below to register your participation to the 12th IMSPQ 2014. Dateline for submission: 31 st March 2014

1. Full name of the university / college that you are representing:

2. Your university / college’s logo (please attach if possible):

3. Team photo: (Can be sent slightly later)Please attach your team photo (including any accompanying lecturer) here (Please match the names with the people in the photo).

4. The total number of delegates (both students and accompanying lecturer / staff) joining the quiz:

Students: Lecturer/ staff:

5. Please list the name (with title) of the accompanying lecturer/ staff :

6. Please list the full name of the students:Male student Female student

(Please indicate the students who require hostel stay by “*”)

7. Number of vegetarian diet required by your delegate members:

8. Do you require any formal invitation letter for VISA application? *Yes/ No(If “yes”, please provide the full postal address to where the letter should be sent)

9. Registration fees : USD 30 per participant

(Registration fees includes student accommodation for 3 nights, food and t-shirt)

(Please refer to the next page for payment method)

10. Payment Method:

Direct bank deposit / Transfer (Please DO NOT mail cheques)Name of Bank : CIMB BankAccount Holders : Ruby Binti Husain, Hoe See Ziau, Nor Zuhaila Binti

Mohamad NorAccount No. : 14400108119522Swift Code : CIBBMYKL (for international transfers)