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literacy-seminar - Rotary International District 3310

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					                                                   DISTRICT 3310 LITERACY SEMINAR 2011

            ORGANIZED BY ROTARY CLUB OF JOHOR BAHRU AND ROTARY CLUB OF JOHOR CENTENNIAL

                                                               Date : 29th JANUARY 2011

                                                                TIME : 9 AM TILL 3PM

                                                   VENUE: GRAND PARAGON HOTEL , JOHOR BAHRU

                                                      REGISTRATION FORM
                                      Johor/Malacca/Singapore/Sabah/Sarawak, District 3310, Rotary International
                            PERSONAL PARTICULARS                                                            REGISTRATION FEE

Full Name: _______________________________________________                            I enclose herewith payment in form of:

Sex:       Male        Female        D.O.B: ______________________                         *RM 80/S$35.00 for Registration per pax

Address: ________________________________________________
                                                                                      Cheque or Cash (Please tick one)
                                                                                           Cheque (Bank/Cheque No: _______________________ )

                                                                                           Cash (*Bank-in/BY HAND only) *Please delete one.
Tel: _________________________ (H) _____________________ (O)
                                                                                      ☺ All payments in cheques must be crossed and made payable to: -
H/P: ______________________ NRIC No: _____________________                               ROTARY CLUB OF JOHOR BAHRU
                                                                                      ☺ Kindly write your name, club and contact number on the back
Email: __________________________________________________                                of the cheque.
                                                                                      ☺ Please do not send cash by mail.
Number to contact in case of emergency: ________________________                      ☺ No refunds will be made upon submission.

                            ROTARY INFORMATION                                                            SPECIAL REQUIREMENT

Have you ever attended Literacy Seminar before ?                                      Please specify e.g. health, handicapped facilities, vegetarian, etc
                                                            Yes              No
If YES, please state: ______________________________________

I am from Rotary Club of _________________________________
                                                                                                                DECLARATION
Position held (2010/2011): __________________________________                         I, the undersigned and as named above, hereby declare that I will
                                                                                      not hold the Organisers or any other parties liable for any
                                       NOTE                                           unforeseen occurrence(s) during the Seminar.

Please send the completed Registration Form and Cheque to:
i) via Postal (Registration Form & Cheque)
                                                                                      Signed: ____________________ Date: ________________
            17-03 Susur Dewata1
            Larkin Perdana                                                                            FOR SECRETARIAT USE ONLY
            80350 JOHOR BAHRU
            Tel :07-2387263 / 07-2387507                                              Date Received: _____________________
            Fax : 07-2387261
                                                                                      Registration No: __________ Payment Received: __________
iii) via Email (Registration Form only)
dshanker76@gmail.com
                                                                                                               CLOSING DATE
For any enquiries, please contact :
1. Organising Chairman              : PP Tan Beng Sooi       +6019-7504649                                 25th January 2011
2. Co-Organizing Chairman          : Pres. Dinesh Shanker    +6012-4671320

				
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