PARTICIPANT DETAILS: (Please type or write your particulars in BLOCK letters and REGISTRATION FORM Full Name: Organisation: Title: Mr. Ms. Mrs. Miss Prof. Dr. other:_______________________ Affiliated Organisation/ Institution: Address: Postcode:______________ Country:___________________ Contact Number : Offi ce Mobil e Fax E-mail: MAPS Membership: Yes, Membership Number:________________________ No membership Participant Type: I wish to attend the conference as a participant I wish to make a presentation I am an Exhibitor Presentation Oral Poster (Size: A1) Presentation Title: Early Registration Fee (before 30 th June 2017) Standard Registration Fee (after 30 th June 2017) Registration Fee: Student (member) MYR 500 MYR 600 Registered MAPS Member MYR 750 MYR 850 Non-member MYR 950 MYR 1050 International Student USD 200 USD 250 International Delegate USD 300 USD 350 Meal Choice Non-Vegetarian Vegetarian Conference Dinner Yes No Mode of payment: Cash Bank draft/ Cheque (for Malaysian only) Bank Draft Number/Cheque Number:____________________ Issuing Bank:________________________ Date of Transaction:____________________ Bank transfer (for Malaysian only) Transfer Receipt Reference Number:_____________________ Issuing Bank:________________________ Date of Transaction:____________________ Bank Cheque (for Malaysian only) Cheque Number:____________________ Issuing Bank:________________________ Date of Transaction:____________________ Local Order (for Malaysian only) LO reference No.:_____________________________ Telegraphic Transfer*: (T.T. Reference No.:____________________ T.T. Bank: __________________________ Date of Transaction:____________________ )

ipc2017.weebly.com · Web viewT.T slip to the Conference Secretariat *Registration will only be confirmed upon receipt of FULL PAYMENT. Cancellation Policy: Cancellation of registration

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Page 1: ipc2017.weebly.com · Web viewT.T slip to the Conference Secretariat *Registration will only be confirmed upon receipt of FULL PAYMENT. Cancellation Policy: Cancellation of registration

PARTICIPANT DETAILS:(Please type or write your particulars in BLOCK letters and tick as ‘√’ where appropriate)

REGISTRATION FORM

Full Name: Organisation: Title: Mr. Ms. Mrs. Miss Prof. Dr. other:_______________________Affiliated Organisation/ Institution:

Address: Postcode:______________ Country:___________________

Contact Number : Office Mobile FaxE-mail:MAPS Membership: Yes, Membership Number:________________________ No membership

Participant Type:I wish to attend the conference as a participantI wish to make a presentationI am an Exhibitor

Presentation Oral Poster (Size: A1)

Presentation Title:

Early Registration Fee(before 30th June 2017)

Standard Registration Fee (after 30th June 2017)

Registration Fee:

Student (member) MYR 500 MYR 600Registered MAPS Member MYR 750 MYR 850Non-member MYR 950 MYR 1050International Student USD 200 USD 250International Delegate USD 300 USD 350

Meal Choice Non-Vegetarian VegetarianConference Dinner Yes No

Mode of payment:

CashBank draft/ Cheque (for Malaysian only)Bank Draft Number/Cheque Number:____________________Issuing Bank:________________________ Date of Transaction:____________________Bank transfer (for Malaysian only)Transfer Receipt Reference Number:_____________________Issuing Bank:________________________ Date of Transaction:____________________Bank Cheque (for Malaysian only)Cheque Number:____________________Issuing Bank:________________________ Date of Transaction:____________________Local Order (for Malaysian only) LO reference No.:_____________________________Telegraphic Transfer*:(T.T. Reference No.:____________________ T.T. Bank: __________________________Date of Transaction:____________________ )