REGISTRATION FORM Echo by 12dgRVD2

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									HANDHELD ECHO WORKSHOP REGISTRATION FORM (PLEASE TYPE/ WRITE CLEARLY IN BLOCK LETTER)

Title: PROF       DR         Mr         Mrs          Ms

Name:______________________________

Gender Male              Female

Organization:_________________________

Tel No:_____________Fax No:____________________ Mobile No:_______________

Address:__________________________________________________________________

Post code::_____________________ City:____________ State:__________

Email:___________________________


□       I will pay by Cash


□       I enclosed a bank draft/money order/cheque no.: ________________made payable to

        “Bendahari Universiti Putra Malaysia”


□       Online banking (no: 12150005004050-CIMB)

Signature: ____________________                                         Date: ____________________

Registration fee (Lecturers/Others)                : RM 100.00

The workshop is limited to only 40 participants.

Please email or fax the bank in slip together with the registration form to:

Dr Adibah Hanim Bt Ismail
Faculty of Medicine and Health Sciences
Department of Family Medicine
Faculty of Medicine and Health Sciences
43400 UPM Serdang,
Selangor Darul Ehsan
Phone: 0389472545                Fax: 0389472328                        Email: nasuha9999@yahoo.com
TERMS & CONDITIONS:-
 Please take note:
 Registration form must be accompanied with payment or proof of payment.
 Fees must be paid din advanced of the event and made payable in Ringgit Malaysia (RM).
 Cancellation of registration:
      Half of the payment will be refunded before 1st of June
      All payment is non-refundable after 1st of June onwards and receipt will be issued on the day of the
         workshop.


(Closing date: 16 June 2012)

								
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