www.haematology.org.my THE IX TH MALAYSIAN NATIONAL HAEMATOLOGY SCIENTIFIC MEETING Kuching I Sarawak I Malaysia I 29 April - 1 May 2011 REGISTRATION FORM (Please use UPPERCASE) _____________________________________________________________________________________________________ Participants Designation: □Prof □Dr □Mr □Ms Family / Surname _____________________________________ First Name ______________________________________________ Department ___________________________________________ Specialization ___________________________________________ Institution / Company ____________________________________________________________________________________________ Address _________________________________________________________________________________________________________ Postal Code _____________________ City ___________________________________ Country _______________________________ Telephone/Mobile _____________________________________________ Fax ____________________________________________ Email Address ___________________________________________________________________________________________________ Special Dietary Requests □ Vegetarian □ Others : ALL PAYMENTS ARE TO BE MADE IN MYR EXCEPT FOR FOREIGN DELEGATES WHOSE PAYMENT IS IN USD - Local payment must be made to the bank account by cheque or bank draft only. Other mode of payment will not be accepted. Cash payment may be allowed for local Kuching delegates. - Foreign payment can be arranged by bank draft or Telegraph Transfer made payable to: “Malaysian Society of Haematology (Kuching), A/C No: 3162624830” PUBLIC BANK BERHAD, JALAN TUN ZAIDI BRANCH, KUCHING; SWIFT CODE: PBBEMYKL3162624830 Date: __________________________________ Signature: _______________________________________ Please return this form by fax, email or mail to: Fax : +6082 461748 Tel : +6012 897 3091 Email : [email protected] Mail : P O BOX 3124, 93760 KUCHING, SARAWAK, MALAYSIA _____________________________________________________________________________________________________ Registration Fee (please tick the appropriate box) Before 14/Feb/11 After 14/Feb/11 On-Site Overseas Delegates □USD200 □USD250 □USD300 Local Delegates □MYR400 □MYR450 □MYR500 Nurses or Paramedic □MYR200 □MYR250 □MYR300 IMPORTANT! If you make payment by Telegraphic Transfer, forward proof of payment e.g. bank-in slip by fax or scan as email attachment for our verification. To avoid wrong registration, you are required to write your name(s) at the back of the Cheque or Bank Draft for our processing.

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Page 1: Registration form msh2011 NEW DATES

www.haematology.org.my

THE IXTH MALAYSIAN NATIONAL HAEMATOLOGY SCIENTIFIC MEETING Kuching I Sarawak I Malaysia I 29 April - 1 May 2011 REGISTRATION FORM (Please use UPPERCASE) _____________________________________________________________________________________________________

Participants Designation: □Prof □Dr □Mr □Ms

Family / Surname _____________________________________ First Name ______________________________________________ Department ___________________________________________ Specialization ___________________________________________

Institution / Company ____________________________________________________________________________________________ Address _________________________________________________________________________________________________________ Postal Code _____________________ City ___________________________________ Country _______________________________ Telephone/Mobile _____________________________________________ Fax ____________________________________________ Email Address ___________________________________________________________________________________________________

Special Dietary Requests □ Vegetarian □ Others :

ALL PAYMENTS ARE TO BE MADE IN MYR EXCEPT FOR FOREIGN DELEGATES WHOSE PAYMENT IS IN USD

- Local payment must be made to the bank account by cheque or bank draft only. Other mode of payment will not be accepted. Cash payment may be allowed for local Kuching delegates.

- Foreign payment can be arranged by bank draft or Telegraph Transfer made payable to:

“Malaysian Society of Haematology (Kuching), A/C No: 3162624830”

PUBLIC BANK BERHAD, JALAN TUN ZAIDI BRANCH, KUCHING; SWIFT CODE: PBBEMYKL3162624830

Date: __________________________________ Signature: _______________________________________ Please return this form by fax, email or mail to:

Fax : +6082 461748 Tel : +6012 897 3091 Email : [email protected]

Mail : P O BOX 3124, 93760 KUCHING, SARAWAK, MALAYSIA _____________________________________________________________________________________________________

Registration Fee (please tick the appropriate box) Before 14/Feb/11 After 14/Feb/11 On-Site

Overseas Delegates □USD200 □USD250 □USD300

Local Delegates □MYR400 □MYR450 □MYR500

Nurses or Paramedic □MYR200 □MYR250 □MYR300

IMPORTANT! If you make payment by Telegraphic

Transfer, forward proof of payment e.g. bank-in slip by fax or scan as email

attachment for our verification. To avoid wrong registration, you are required to write your name(s) at the back of the

Cheque or Bank Draft for our processing.

$Drivervisor REGISTRATION FORM · 2015 DATES. 2015 DATES. 1. 2. 1. 2. Youth's Name $if applicable$ - A "Drivervisor" is any\radult willing to drive and supervise our young adult$