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Insurex Delegate Registration Form

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					                     9th Annual INSUREX Conference 2012
                               9th October 2012
              The Westin Dubai Mina Seyahi Beach Resort & Marina
                               www.insurex.me

                                         Delegate Form

         Please Complete the below form and Fax/ Mail back to Mediaquest Corp

Fields marked with * are mandatory.

Title *: Mr. Ms. Mrs.

First Name*: _________________________________________________________

Surname*: ____________________________________________________________

Preferred name for delegate badge*: ______________________________________

Company/Association*: _________________________________________________

Position *:_____________________________________________________________

Office Telephone: _______________________________


Mobile *: _______________________________________

Email *: ________________________________________




CONFERENCE FEES:-

Delegate Prices:
 Early bird registration fees before 17th June 2012 – USD $600 per delegate
 Standard registration fees after 17th June 2012 –USD $800 per delegate
(Inclusive of Conference & INSUREX Awards Gala Dinner)

Corporate Group Bookings:
 Purchase 5 delegate Packs and get 1 for Free
 Purchase 10 delegate Packs and get 3 for Free




                                                                  nd
                  P.O Box 72184 Dubai Media City, ZEE Tower Bldg, 2 Floor, Office# 206
                             Tel: 00971 4 391 07 60 / Fax: 00971 4 390 87 37
Payment Method

Payment Currency: US Dollars/ UAE Dirhams
Conversion Rate: 3.67

 Cash
 Cheque/ Draft (payable to Medialeader FZ LLC)
 Bank Transfer to A/c No.: AED 035 321009 001
                              USD - 035 321009 100
                             Euro – 035 321009 101
IBAN AED – AE350200000035321009001
IBAN USD – AE780200000035321009100
IBAN EUR – AE510200000035321009101
Bank: HSBC Bank Middle East Limited,
 Jebel Ali Branch, PO Box 66, Dubai - UAE
Swift Code: BBMEAEAD.
*Bank charges should be borne by the client only.
 Credit Card (Payment can be made online)
www.insurex.me

Terms & Conditions
   1. Payment Terms: Following completion and return of the registration form, full payment is required
       within 7 working days from receipt of invoice.
   2. PLEASE NOTE: Payment must be received prior to the conference date. Due to limited conference
       space, we advise early registration to avoid disappointment. Mediaquest reserves the right to refuse
       admission if payment is not received on time.

2. Substitution: Provided the total fee has been paid, substitutions at no extra charge up to 1 week prior the
event are allowed.

3. Cancellation: In case of cancellations, request must be received in writing by mail or fax within 1 week from
the date of registration of which the fee will then be refundable. After 1 week of registration any cancellation
made will be non-refundable. Non-attendance does not constitute cancellation.

4. Copyright: All intellectual property rights in all materials produced or distributed by Mediaquest Corp in
connection with this event is expressly reserved and any unauthorized duplication, publication or distribution is
prohibited.

5. Important note: While every reasonable effort will be made to adhere to the advertised package, Mediaquest
Corp reserves the right to change event dates, sites or location as it deems necessary without penalty and in such
situations no refunds, part refunds or alternative offers shall be made.

Client acknowledges that they have read and understood all terms and conditions of this contract.

Authorisation:
This Booking is invalid without a Signature



Signature(s): ______________________                                        Date:    /  / 

                                                                          nd
                    P.O Box 72184 Dubai Media City, ZEE Tower Bldg, 2 Floor, Office# 206
                               Tel: 00971 4 391 07 60 / Fax: 00971 4 390 87 37

				
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