Registration Form
Please print
Complete Name: _____________________________________________________________________________________________________
Profession: __________________________________ PRC No. _____________________ Expiry Date: ________________________________
Institution/Company: _________________________________________________________________________________________________
Institution Address: __________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Mobile No: _________________________________________ Email Address: _________________________________________________
How did you learn about this convention? (Pls check all that applies) ___ Flier, ___ Poster, ___ Email, ___ ADNEP website, ___ Text,
___ Colleague, ___ Newspaper, ___ Other _____________________ Attending the Fellowship night? __ Yes __ No
What motivated you to attend this convention? (Pls rank according to priority – 1st, 2nd, 3rd, etc…)
___ Convention Topics, ___ Expertise of Speakers, ___ Venue, ___ Reasonable Price, ___ CPE Units, ___ Other _________________
Please fill in the remaining payment details before sending this through fax:
Branch of payment: _______________________________ Date of Transaction: ________________________
Time of Transaction: _______________________________ Amount: _________________________________
Contacts
0922.887.51.64
0999.517.74.66
0932.417.85.17
Office Address:
Millan Mendoza
Tel: (02) 941.98.56
Menchie C Mangalino
Website: www.adnep.org
94 new 571 old Apitong Street
Marikina Heights, Marikina City
***********************************
Boni Avenue,
Association of
invites you to the
Empowered for
Diabetes Nurse
Scientific Forum
Educators of the
January 20, 2012,
Mandaluyong City
New Horizon Hotel,
Independent Practice
Philippines, Inc (ADNEP)
Diabetes Nurse Educators:
Annual General Assembly and
Fee
Welcome Yearly Please fax or email validated deposit slip
Fee Membership
Fee with the registration form immediately to:
Objectives
Trained DNE 800.00 300.00
with Active Attention: ADNEP
The ADNEP General Assembly seeks to Membership* Telefax: (02) 941-98-56 or (02) 584-6992
achieve the following objectives: Trained DNE 1,300.00 300.00 Email: register@adnep.org
with Inactive
Membership
1. Develop the spirit of entrepreneurial
nursing practice. *Those who attended the 2011 GA and/or
2. Employ innovative diabetes education those who paid their 2011 membership fee
and management. For check payments, please make check pay-
The registration fee includes kit plus 2 able to Association of Diabetes Nurse
Topics snacks and 1 lunch for 1 day and Certifi- Educators of the Philippines, Inc. Per-
cate with CPE units. sonal checks are not accepted.
1. Business Planning for Independent Prac-
tice II. Cash
2. The DNE Entrepreneur Experience
3. DOH and the DEs Very limited slots available. To reserve
1. Mr. Millan Mendoza
4. Research Presentation on Diabetes Edu- your seats, please deposit a non-refundable
ISDFI Building
cation 500 pesos initially on or before Dec 31,
94 Apitong Street,
5. Ergonomics in the Workplace 2011 and pay the rest of the payments
Marikina Heights, Marikina City
6. Insulin Injection Technique: Does it mat- on January 20, 2012. Mobile no. 0932.417.85.17
ter? Tel no. 941-98-56
Participants Fees may be paid:
ADNEP Graduates (active and inactive) I. Bank Deposit
Date and Time Account name: Dress code:
January 20, 2012 Association of Diabetes Nurse Educators of Business/ Smart Casual Attire
Friday the Philippines, Inc
8:00 am – 5:00 pm Account No.: 300-253-257 .
Bank: BDO Thank you and see you on
Venue Branch: SM Sta Mesa January 2012!
New Horizon Hotel
Boni Avenue, Mandaluyong City