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Delegate Registration Form

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					                                    Delegate Registration Form
To be completed after reading the registration information in BLOCKLETTERS. Please check (√) the appropriate boxes. For more details,
see the conference website: www.acem2011.org Please type or print legibly. Return all 3 pages as an email attachment to
registration@lawson-marsh.com or by fax to +66 2 940 2382


Personal Information

Delegate No. 01 Title:      Name:                                              Position:

Mob:                                Email:                                     Join Congress Party:     Yes     No

Passport Detail:                                     Arrival Flight                        Departure Flight

Delegate No. 02 Title:      Name:                                              Position:

Mob:                                Email:                                     Join Congress Party:     Yes     No

Passport Detail:                                     Arrival Flight                        Departure Flight

Delegate No. 03 Title:      Name:                                              Position:

Mob:                                Email:                                     Join Congress Party:     Yes     No

Passport Detail:                                     Arrival Flight                        Departure Flight

Delegate No. 04 Title:      Name:                                              Position:

Mob:                                Email:                                     Join Congress Party:     Yes     No

Passport Detail:                                     Arrival Flight                        Departure Flight

Delegate No. 05 Title:      Name:                                              Position:

Mob:                                Email:                                     Join Congress Party:     Yes     No

Passport Detail:                                     Arrival Flight                        Departure Flight

Delegate No. 06 Title:      Name:                                              Position:

Mob:                                Email:                                     Join Congress Party:     Yes     No

Passport Detail:                                     Arrival Flight                        Departure Flight

Company Information

Organization:                                        Contact Person:                                Position:

Address:

Tel:                         Fax:                               Mob:                                Email:

Sponsor Information

Sponsor by:                                          Contact Person:                                Position:

Address:

Tel:                         Fax:                               Mob:                                Email:




                                                                      1
                                          Delegate Registration Form

                                                                                        Regular Fee                                            On-site Fee
      ( A ) CONFERENCE REGISTRATION FEE
                                                                                     Until 31 May 2011                                     After 31 May 2011
Physician                                                                                 USD 420                                                USD 550

Physician (Least-Developed Countries)                                                     USD 400                                                USD 500

Residents | Trainees | Nurse | Technician                                                 USD 350                                                USD 400

Accompanying Person                                                                       USD 200                                                USD 250



     Total Physician                                                        Person     Delegate No                                     Total                               USD

     Total Physician (Least-Developed Countries)                            Person     Delegate No                                     Total                               USD

     Total Residents, Trainees, Nurse, Technician                           Person     Delegate No                                     Total                               USD

     Total Accompanying Person                                              Person     Delegate No                                     Total                               USD

                                                                                                               Subtotal                                                    USD

                                                                                                               VAT 7%                                                      USD

                                                                                                               Grand Total (A)                                             USD



( B ) CONFERENCE GROUP REGISTRATION FEE



                 Above 10-50 Delegates                                  850 USD per person including 3 nights accommodation


                   Above 50 Delegates                                   800 USD per person including 3 nights accommodation



                                                                                                               Subtotal                                                    USD

                                                                                                               VAT 7%                                                      USD

                                                                                                               Grand Total (B)                                             USD

Remark:
1.    The Registration fee covers activities including the following:
                  a.    Name badge, conference bag, final program book and abstract book.
                  b.    Admission to all scientific sessions and exhibition area.
                  c.    Invitation to opening ceremony and welcome reception.
                  d.    Daily Lunch + 2 Coffee Break and refreshment during the conference period
                  e.    Certificate of attendance
2.    Registration fees for resident / fellow / nurse & technician will be granted only to those whose document their position and official statement from the head of their
      department or institution. Nurses may provide a copy of their nursing license.
3.    Accompanying person will allow to accessing only exhibition area, having lunch and refreshments.
4.    Least-Developed Countries: Angola, Bangladesh, Benin, Burkina Faso, Burundi, Cambodia, Central African Republic, Chad, Congo, Democratic Republic of
      the Djibouti, Gambia, Guinea, Guinea Bissau, Haiti, Lesotho, Madagascar, Malawi, Maldives, Mali, Mauritania, Mozambique Myanmar, Nepal, Niger, Rwanda,
      Senegal, Sierra, Leone, Solomon Islands, Tanzania, Togo, Uganda and Zambia.
5.    7% VAT is excluded.
6.    Group package is including of conference registration, 3 night accommodation and breakfast. Workshop fee is excluded.




                                                                                      2
                                 Delegate Registration Form

( C ) WORKSHOP FEE                                                                                                                                Fee
Basic Disaster Life Support                     | WS1
Venue               TBC                         |
Date & Time
                     nd          rd
                    2 July or 3 July 2011       | 08:30 – 16:30                                                                               150 USD
Duration            1 Day                       |
Combat Life Saver Course                        | WS2
Venue    Phramongkutklao Hospital & College of Medicine, Bangkok
Date & Time         2 -3 July 2011              | 08:30 – 16:30                                                                                70 USD
Duration            2 days                      |
Toxicological and Hazmat Life Support Asian Pacific Edition | WS3
Venue    Siriraj Hospital, Bangkok
Date & Time         2 -3 July 2011              | 08:30 – 16:30                                                                               200 USD
Duration            2 days                      |
Workshop of Asian Perspective of Snake Bite Management | WS4
Venue    Queen Saovabha Memorial Institute, Thai Red Cross Society Bangkok
Date & Time         2 -3 July 2011              | 08:30 – 16:30                                                                               200 USD
Duration            2 days                      |
WINFOCUS Emergency Echocardiography Hands on and Simulation Course
ECHO Course | WS5                                                                                                                             350 USD*
Venue    King –Chulalongkorn Surgical Training Unit, Bangkok                                                                           (Least Developed countries)
Date & Time         1 - 2 July 2011             | 08:30 – 16:30                                                                               500 USD
Duration            2 days                      |
WINFOCUS Emergency Ultrasound Guided Invasive Procedure Emergency and Critical Care (Soft Cadaver) | WS6                                      330 USD*
Venue    King –Chulalongkorn Surgical Training Unit, Bangkok
                                                                                                                                       (Least Developed countries)
Date & Time         3 July 2011                 | TBC
Duration            1 days                      |                                                                                             410 USD
EMS Leaders and Medical Directors Workshop | WS7
Venue    Rajavithi Hospital
Date & Time         2 -3 July 2011              | 08:30 – 16:30                                                                               350 USD
Duration            2 days                      |
Simulation Training Courses: Crisis Resource Management | WS8
Venue    Rajavithi Emergency Medicine Simulation Training Center, Rajavithi Hospital, Bangkok
Date & Time         2 July 2011                 | 08:30 – 16:30                                                                               350 USD
Duration            1 days                      |
Emergency Invasive Procedures Soft Cadaver | WS9                                                                                              400 USD*
Venue     Accident & Emergency Medicine Center, Ramathibodi Hospital, Bangkok                                                          (Least Developed countries)
Date & Time:        2 July 2011                | 08:00 – 17:00
Duration            1 days                     |                                                                                              450 USD
New Techniques in C-A-B (Circulation-Airway-Breathing) | WS10
                                                                                                                                              170 USD*
Venue     Accident & Emergency Medicine Center, Ramathibodi Hospital, Bangkok
Date & Time         3 July 2011                | 0800 - 1600                                                                           (Least Developed countries)
Duration            1 day                      |                                                                                              220 USD
Critical Patient Transfer : Ground and Air Ambulance      | WS11
                                                                                                                                              100 USD*
Venue     Bangkok General Hospital
Date & Time         2 July 2011                | 0830 - 1600                                                                                 (Lecture Only)
Duration            1 day                      |                                                                                              220 USD
Literature Appraisal workshop on Therapy and Diagnosis | WS12
Venue     Accident & Emergency Medicine Center, Ramathibodi Hospital
Date & Time         3 July 2011                | 0830 - 1600                                                                                  150 USD
Duration            1 day                      |
   Code     Person         Delegate No.            Total USD              Code         Person            Delegate No.                    Total USD

   WS1                                                                       WS7

   WS2                                                                       WS8

   WS3                                                                       WS9

   WS4                                                                    WS10

   WS5                                                                    WS11

   WS6                                                                    WS12

                                                                                                                    Subtotal

                                                                                                                  VAT 7%

                                                                                                          Grand Total (C)
                                              Remark: All workshops are for limited number of student. The registrations are on first come first serve basis.




                                                                         3
                                           Delegate Registration Form
                                                                                                                                           Room type
                                         ( D ) ACCOMMODATION
                                                                                                                               Single                        Double

                              Centara Grand at CentralWorld Hotel | 5 Star Hotel | Standard Room                              160 USD                        170 USD

                       Grand Millennium Sukhumvit Bangkok Hotel | 5 Star Hotel | Standard Room                                120 USD                        130 USD

                                         Renaissance Bangkok Hotel | 5 Star Hotel | Standard Room                             145 USD                        145 USD

                                    Amari Watergate Bangkok Hotel | 5 Star Hotel | Standard Room                              135 USD                        145 USD

                                                                                                 Deluxe Room                  135 USD                        145 USD
                                                    VIE Hotel Bangkok | 4 Star Hotel
                                                                                                  Deluxe Suite                165 USD                        180 USD

                                              Holiday Inn Bangkok | 4 Star Hotel | Standard Room                              135 USD                        145 USD

                              Courtyard by Marriott Bangkok Hotel | 3 Star Hotel | Standard Room                              130 USD                        140 USD

                                         Arnoma Hotel Bangkok | 3 Star Hotel                | Standard Room                   105 USD                        120 USD

                                                                                            Room preference                    Smoking                     Non-Smoking




Hotel Name                                                                Check In                                        Check Out

                                                            Single                      Room(s)                    Night(s)                                              USD
                       Standard Room
                                                            Double                      Room(s)                    Night(s)                                              USD


                       Deluxe Room*                         Single                      Room(s)                    Night(s)                                              USD
Room Type
                  Only VIE Hotel Bangkok                    Double                      Room(s)                    Night(s)                                              USD


                       Deluxe Suite*                        Single                      Room(s)                    Night(s)                                              USD

                  Only VIE Hotel Bangkok                    Double                      Room(s)                    Night(s)                                              USD

                                                                                                         Grand Total (D)                                                 USD


Remark
  - Breakfast, VAT and service charge are included.


Cancellation Policy
  - Notification must be submitted to the conference secretariat in writing. The effective date of cancellation will be the date on which the conference secretariat receives the
     written notice.
  - If a registrant is unable to attend an event for any reason they may substitute, by arrangement with the registrar, someone else from the same institute / organization.
  - Cancellation within 5th April 2011 will be refunded 90% of the registration fees.
  - Cancellation within 5th May 2011 will be refunded 50% of the registration fees.
  - Cancellation after 5th May 2011 will not be eligible for a refund.
  - For registrations cancelled after 5th May 2011 that include accommodation we will attempt to refund the accommodation costs. However as we pay for conference
     accommodation in advance, cancellation less than 3 months before event will be charged for one night cancellation fee.
  - All refund will be made after 6th July 2011 with 20USD handling fee.




                                                                                        4
                                     Delegate Registration Form

                           (E) AIRPORT TRANSFER


Airport Pick Up / Transfer Limousine Service (1-way : Airport – Hotel)                50 USD / Car (2 people)              70 USD / Van (8 people)


Airport Pick Up / Transfer Limousine Service ( 2-way : Airport – Hotel - Airpot)      90 USD / Car (2 people)              120 USD / Van (8 people)



Airport Pick Up / Transfer Limousine Service (1-way: Airport – Hotel)

Total                         Car                                                  USD       Arrival Date            /      /

Total                         Van                                                  USD       Arrival Time

Subtotal                                                                           USD       Flight No                     Airline

VAT 7%                                                                             USD

Grand Total (1-Way)                                                                USD

Airport Pick Up / Transfer Limousine Service (2-way: Airport – Hotel - Airport)

Total                         Car                                                  USD       Arrival Date            /      /

Total                         Van                                                  USD       Arrival Time

Subtotal                                                                           USD       Departure Date          /      /

VAT 7%                                                                             USD       Departure Time

Grand Total (2-Way)                                                                USD       Flight No                     Airline

Grand Total (E) (1-Way plus 2-Way)                                                 USD



                                    (F) TOUR PACKAGE                                                        Person                   Total USD

                          Grand Palace & The Emerald Buddha Image Temple Tour 40 USD
                                                                                                                                                 USD
                                                            July    2     3       7      8, 2011
                Vimanmek Mansion Tour ( world's largest golden teakwood mansion) 85 USD
                                                                                                                                                 USD
                                                            July    2     3       7      8, 2011
                                          Grand Palace & Vimarnmek Mansion Tour 90 USD
                                                                                                                                                 USD
                                                            July    2     3       7      8, 2011
                                                   Bangkok's Temples and City Tour 30 USD
                                                                                                                                                 USD
                                                            July    2     3       7      8, 2011
                                                 Bangkok River Cruise & Canal Tour 50 USD
                                                                                                                                                 USD
                                                            July    2     3       7      8, 2011
                               Ancient City (Thailand Open Theme Grand Exhibition) 70 USD
                                                                                                                                                 USD
                                                            July    2     3       7      8, 2011
                               Ayutthaya-Ancient Capital of Thailand (650 years old) 65 USD
                                                                                                                                                 USD
                                                            July    2     3       7      8, 2011

                                                                                                         Grand Total (F)                         USD



                       Package Include: Hotel pickup and drop off, meal as in program and English Speaking guide (minimum 2 person in operation)




                                                                          5
                                      Delegate Registration Form

PAYMENT DETAILS

Total (A)                                                                                                            USD

Total (B)                                                                                                            USD

Total (C)                                                                                                            USD

Total (D)                                                                                                            USD

Total (E)                                                                                                            USD

Total (F)                                                                                                            USD

Grand Total (ALL)                                                                                                    USD




PAYMENT METHOD                                                              AUTHORIZATION

*Payment is required within 7 working days on receipt of invoice.
                                                                            Name:

    Bank Transfer
                                                                            Position:
 A/C Name            ACEM2011
 Saving A/C No       039-0-33079-5                                          Signature:                                    Date:          /         /
 Bank Name           Krung Thai Bank Public Company Limited
                                                                            Signatory must be authorized to sign on behalf of contracting person. This booking is
 Branch              Pahonyothin Soi 39, Ladprao, Bangkok, Thailand         invalid without a signature.
 Swift Code          KRTHTHBK
 Remark: International bank transfer charges are paid by the payer.


    Credit Card
 Please debit my                   Visa                MasterCard                       Amex


 Card Holder’s Name:
 Card Number:




 Security Code:




 Expired Date:          /                           V-Code (CVS)


 Signature:                                         Date            /   /
 Note: There is an additional charge of 4% for credit card charges and 5% credit card charges for AMEX cards.




            Please fax to +66 2 940 2382 or email: registration@lawson-marsh.com
More information, please contact

Lawson-Marsh Events Co., Ltd.

1/70 - 71 Soi Phaholyothin 40 Phaholyothin Road, Senanikom, Jatujak Bangkok 10900, Thailand

Tel: +66 (0) 2940 2480-6 | Fax: +66 (0) 2940 2484 | E-mail: registration@lawson-marsh.com




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