APDW 2012 Individual Registration Form by 5x7V3m

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									For Internal Use Only: APDW 2012 _________

Asian Pacific Digestive Week 2012
5-8 December 2012 * QSNCC, Bangkok, Thailand
REGISTRATION FORM

   Please PRINT in BLOCK LETTERS and FAX, EMAIL or AIRMAIL to:

                                     Registration and Accommodation Dept. 10 Soi Lasalle 56, Sukhumvit Road, Bangna, Bangkok 10260, Thailand
                                     Tel: +66 2 7487881          Fax: +66 2 7487880             E-mail : secretariat@apdw2012.org




Accompanying Person:

Family Name                                                                            First name

Registration Fees (in US Dollars)

                                                                                            Early Bird                 Regular Rate               Onsite Rate
                             Registration Categories
                                                                                        Valid until 30 Sept            1 Oct -19 Nov              After 19 Nov
  International Delegate                                                                       $400                        $450                       $600
  Trainees/Residents                                                                           $250                        $300                       $500
  Accompanying Persons                                                                         $200                        $225                       $300
  Pre-Conference Courses (Post-Graduate Course, Endoscopy Directors’                           $250                        $300                       $350
  Workshop, Live Endoscopy Workshop on 5 Dec)
  Hands-On Workshop in Advanced Endoscopy with Animal Models                                     $400                        $450                      $500
  (on 7 Dec)
  CME Accreditation                                                                               $20                         $20                       $20

Registration Fee Inclusions

International Delegates and Trainees/Residents                       Pre-Conference Course (5 December 2012)
 Admission to scientific sessions from 6-8 Dec                       Admission to pre-conference courses offered at QSNCC on 5 Dec specifically the Post-Graduate
 Admission to industry satellite symposia on 6-8 Dec                   Course, Endoscopy Directors’ Workshop, and Live Endoscopy Workshop
 Lunch and coffee breaks on 6-8 Dec                                  Admission to industry satellite symposia on 5 Dec
 Welcome Reception on 5 Dec                                          Lunch and coffee breaks on 5 Dec
 Conference material including final program, abstract book & bag    Welcome Reception on 5 Dec
 Admission to the industrial exhibition from 5-8 Dec                 Conference material including final program, abstract book & bag
                                                                      Admission to the industrial exhibition on 5 Dec



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APDW 2012                                                                           Participant’s name _______________________________________

 Accompanying Persons                                                       Hands-On Workshop in Advanced Endoscopy with Animal Models (7 Dec)
  Welcome Reception on 5 Dec                                                Admission to the “Hands-on Workshop in Advanced Endoscopy with Animal Models” offered at
  Lunch and coffee breaks on 5-8 Dec                                         King Chulalongkorn Memorial Hospital on 7 Dec
  Admission to the industrial exhibition from 5-8 Dec                       Lunch and morning coffee break on 7 Dec
  Accompanying Persons’ tour                                                Round-trip transportation from QSNCC to King Chulalongkorn Memorial Hospital on 7 Dec
                                                                             Workshop material
Attendance to Functions
This is the Pre-Conference Course that I will attend on Dec 5 Registration Fee at $250(Early Bird)/ $300 (Regular Rate)/ $350 (Onsite Rate)
           Live Demo Endoscopy                Post Graduate Course               Endoscopy Directors' Workshop
Welcome Reception, 5 Dec 2012 at 18.00H, QSNCC                  Admission is Free            I will attend.               I will not attend.
If attending any of the Meet-the-Experts sessions, please tick which session you will attend on the following dates:
          6 December                          7 December                           8 December
           Meet-the-Experts A,B               Meet-the-Experts E,F                Meet-the-Experts I,J
           Meet-the-Experts C,D               Meet-the-Experts G,H                Meet-the-Experts K,L

How did you learn about this congress? (Please choose one)
 Colleague / Co-worker      Congress Brochure       E-mail Newsletter  Sponsor  Search Engine (i.e. Google)
 Society/Professional Websites  Online/Print Journal  Internet event calendars  Online Discussion Groups  Other
Please indicate type of facility where employed (choose one)
 Hospital      University  Private practice  Research institute  Laboratory  Industry  Press
 Comprehensive Care Clinic  Government agency  Others - please specify ___________________
Please indicate your professional role (choose one)
 Clinical practitioner     Clinician researcher     Basic science researcher    Epidemiology/Statistics Nurse/Healthcare practitioner
 Health administrator      Industry/Corporate professional    Student      Resident/Research Fellow  Others - please specify ____________
Please indicate your specialty field (choose one)
 Gastroenterology  Hepatology  Nutrition and Dietetics  Surgery  Pediatrics  Radiology  Others - please specify ________________
Please indicate your clinical interests (choose up to two)
 Colon Cancer  Eating Disorders  Endoscopy  Food allergy  Gastric Cancer  GI Surgery  Hepatocellular Carcinoma  Inflammatory
Bowel Disease  Laparoscopic Surgery  Lipid disorders  Liver Transplantation  NAFLD/NASH  Oesophageal Disorders  Pancreatic Cancer
 Pancreatology  Paraenteral/Enteral nutrition  Viral Hepatitis  Others - please specify _______________
Please indicate your dietary preferences (choose one)
 No preference  Vegetarian  Halal  Others – please specify ____________________________________

Payment
Please indicate the amount enclosed and preferred mode of payment. Ensure that you send your fully completed registration and accommodation form
together with your payment:
Registration Fee:                        US $ __________
Accompanying Person Fee:                 US $ __________
Pre-Conference Courses:                  US $ __________
Total:                                   US $ _______

 Option 1: Credit Card
                    Visa                        MasterCard


Number                                                                          Expiry Date (month/year)                    Verification No.
Name as shown on card:


Family Name                                                                                    First name

Signature
                                                                                              Date (day/month/year)                      Passport number

 Option 2: Bank Transfer - with your name and address indicated on the reverse. If payment is made for more than one person or by a company,
please make sure all names are indicated and send fully completed registration and accommodation forms together with a copy of the bank transfer.
Please make bank transfers payable to:

Bank Account Information
 Bank Account No                        :    0003-007586-01-4                                 Bank Name                 :     DBS Bank Ltd, Singapore
 Bank Account Name                      :    Kenes MP Asia Pte Ltd                            Bank Address              :     6 Shenton Way, DBS Bldg Tower 1
 SWIFT                                  :    DBSSSGSG                                                                         Singapore 068809

*Bank charges are the responsibility of the participant and should be paid at source in addition to the registration and accommodation fees.
*Please make sure the name of the conference and the participant are stated on the bank transfer.

CANCELLATION POLICY – Registration                                                        CANCELLATION POLICY – Hotel Accommodation
 The APDW 2012 Conference Secretariat must be notified by e-mail or fax                         Cancellation and refund policy vary from one hotel to another.
 of your intent to cancel registration. Cancellation refund schedule is as                      Credit card details are required for hotel reservations.
 follows:                                                                                       All payments should be made directly to the hotel upon check-out.
 -Notifications received no later than 20 Sept 2012 will be refunded in full less US$
 20 handling and bank charges.
 -Notifications received between 21 Sept – 5 Nov will be refunded 50%
 -No refund on notifications received after 5 Nov 2012.

Date                                                                         Signature
       By signing this form you authorize Kenes Asia to charge the above credit card for the balance of your account two weeks prior to your arrival for services rendered.

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