20th RCD Registration Form - local
20th REGIONAL CONFERENCE of DERMATOLOGY [ A s i a n - A u s t r
a l a s i a n ]League of ASEAN Dermatological SocietiesEMERGING
CONCEPTS & PARADIGM SHIFTS IN DERMATOLOGYFebruary 20-23, 2012
EDSA Shangri-La Hotel Mandaluyong City, PhilippinesR E G I S T R A
T I O NF O R Mf o rP h i l i p p i n eD e l e g a t e sREGISTRATION
FEES(Please check boxes appropriately)CategoryEarly
RegistrationUntil November 20, 2011November 21, 2011 - January 21,
2012From January 22, 2012& on-site registration
PDS Members in Good Standing P 10,000.00 P 10,000.00 P
15,000.00
Non PDS Members/PDS Members Not in GoodStanding P 30,000.00
Resident/Trainee** P 8,000.00 P 8,000.00 P 10,000.00
DELEGATE(Please fill-in ALL the blanks and check boxes
appropriately)Title: Prof Dr Mr Mrs Ms
Last Name: TanFirst Name: Thelma
Institution: Manila Skin Clinic
Medical Society Membership: PMA, PMS, IDS, ICS, PCAM
Address: Manila Skin Clinic RM 403 Jalandoni Bldg. R. Salas St.
Ermita Manila
Postal Code: 1000
Telephone: 5252549Fax: 9522097Mobile: 09175269225 Email:
[email protected]
**RESIDENT PHYSICIAN / TRAINEE CERTIFICATIONI certify that is a
full time Dermatology resident trainee.
Name of Institution:
Head of College/Department:
Authorized Signature:
page 1 of 2TICKETED COURSES (NO FEE)Kindly indicate your
preferred course. Limited attendance only.*Course ticket
required*Course subject to availabilitySpecial Meal Requirement
Halal Vegetarian
Social Events Welcome Dinner Fellowship Night
PAYMENT PLAN (Please check boxes appropriately) Check
BDO # 0197223 Bank DepositBDO Quezon Avenue Heroes Hills
Branch
Cancellation Policy:Registration cancelled Before November 20,
2011 will be subject to a 50% refund.There will be NO REFUND if
cancellation is made after November 20, 2011.Please fill up the
form appropriately and send it to the Congress Organizing
Center:20th REGIONAL CONFERENCE OF DERMATOLOGY c/o Philippine
Congress Organizing Center (PCOC) Block 6 Lot 8Camella Homes,
Alabang 1Muntinlupa City 1770,
PhilippinesEmail:[email protected]:www.rcd2012.comTelephone:(+63-2)
809-9229Telefax:(+63-2) 659-1509Mobile:(+63-917) 887-8669
For more information, please contact:PHILIPPINE CONGRESS
ORGANIZING CENTER (PCOC) Contact Persons: Tony M. Ang or Lita
Ang-de JesusEmail:[email protected]:(+63-2)
809-9229Telefax:(+63-2) 659-1509Mobile:(+63-917) 887-8669
You will receive confirmation within 24 hours from us.If you are
a PDS member, your good standing status will be ascertained and a
payment instruction sheet will be sent to you by email. Thank
you.page 2 of 2
1st Choice2nd ChoiceLaser CoursePediatric Dermatology
CourseMedical Dermatology CourseProcedural Dermatology Course
