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Advances in Facial Plastic Surgery and Rhinology and Pre

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					                                   Advances in Facial Plastic Surgery and Rhinology
                                      and Pre-conference Cadaveric Workshops
                                        Prince of Wales Hospital, Hong Kong
                                                        Registration Form
(1) Complete this registration form in BLOCK LETTERS and return with the appropriate registration fee to the Secretariat; OR
(2) Register online at our website www.ent.cuhk.edu.hk/entconf2011
  Salutation:                  Professor              Doctor        Mr.                Ms.
  Surname:                                                         Given Name:
  Position:                                                      Department:
                               Facial Plastic    Rhinology/Skull Base    Plastic, Reconstructive and Aesthetic Surgery
  Subspecialty                 Oral and Maxillofacial Surgery            Others_____________________________
  Institution:
  Mailing Address:
                                                                   Country:
  Tel:                                                             Fax:
  Email:
    I am a member of the Pan Asia Academy of Facial Plastic & Reconstructive Surgery / American Academy of Facial &
    Plastic Reconstructive Surgery / European Academy of Facial Plastic Surgery / Brazilian Academy of Facial Plastic
    Surgery / Mexican Society of Rhinology & Facial Plastic Surgery / Australasian Academy of Facial Plastic Surgery.
    (delete as appropriate)

    I am a delegate from Asia / Australasia region.
    I am most interested in the   Facial Plastic Programme        Rhinology/Skull Base Programme (please tick one for our
    conference logistic arrangement.)

 Registration Category
  Main Conference (7 - 9 December 2011)
                                                                                 On or before 1 Sep       After 1 Sep
         Member of Pan Asia Academy of FPRS / American Academy of
         FPRS / European Academy of FPS / Brazilian Academy of FPS /
         Mexican Society of Rhinology & FPS / Australasian Academy                      HK$3,000           HK$4,000
         of FPS
         Delegate from Asia / Australasia region
         Delegate from other regions                                                    HK$4,000           HK$5,000
      Trainee (Proof required)                                                          HK$2,000           HK$2,500
  Pre-conference Cadaveric Workshop
      Rhinoplasty Dissection Course (5 December 2011)                                          HK$15,000
                                                                Grand Total HK$
  Payment Method
     Credit Card Payment             Visa      MasterCard      Card Issuing Bank
                                  Surname                                 Given Name
     Cardholder’s Name

     Card Number

     Expiry Date                  (mm/yyyy)                                   Amount HK$

     Signature of Cardholder

      A bank draft for HK$______________ payable to "The Chinese University of Hong Kong".
     Personal cheque for the amount of HK$ ________________ made payable to "The Chinese University of Hong Kong". (For
     Hong Kong residents only)



                   Signature of Applicant                                                          Date
Remarks to Participants of Rhinoplasty Workshop:
   Instruments will be provided but course delegates are welcome to bring their own instruments. Please kindly
   inform the secretariat if you wish to do so for inventory purposes.
   Two participants will share one cadaver head.
   All participants will agree to follow Professor Palma’s step-by-step command so as to fully understand the
   rhinoplasty dissection. Participants are to perform each step as group without deviation.
   Local faculty will be present to supervise dissection tables.
   Limited places granted on a first-come-first-served basis to the following specialty surgeons with an interest in
   rhinoplasty:
                             ENT and Facial Plastic Surgeon
                             Plastic, Reconstructive and Aesthetic Surgeon


 Payment, Cancellation and Refund Policy:
   Please note that full payment must be received for early bird fee no later than 1 September 2011 to ensure you
   receive the early bird discount. After that date, unpaid early bird registrations will automatically be increased to the
   standard fee.
   All cancellations must be made in writing to the Secretariat. The following refund policy will be observed:
                                                                       Refund of registration fee less an
           Postmarked, faxed or email on or before 1 September         administration charge of HK$450
           Postmarked, faxed or email after 1 September                No refund

   Should the programme scheduled have to be cancelled due to unforeseeable circumstances, the organizer shall try
   to re-schedule the programme whenever possible. There will be no refund if the delegate cannot attend the re-
   scheduled programme. If, for reasons beyond the control of the Organizing Committee, the 2011 CUHK ENT
   Conference, and/or its pre-conference workshops are cancelled, registration fees will be refunded after the
   deduction of conference expenses already incurred.


 Conference Secretariat:
 Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong
 6/F, Clinical Sciences Building, Prince of Wales Hospital, Shatin, Hong Kong

 Tel No.   :   (852) 2632 1277
 Fax No.   :   (852) 2145 8876
 Email     :   entconf@ent.cuhk.edu.hk
 Website   :   www.ent.cuhk.edu.hk/entconf2011