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20TH ACCSQ-PPWG - REGISTRATION FORM
20TH ACCSQ-PPWG - REGISTRATION FORM
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20TH ACCSQ-PPWG - REGISTRATION FORM

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  1. 20 PPWG nUSA DUA the th ACCSQ bali ASEAN CONSULTATIVE COMMITTEE FOR STANDARDS AND QUALITY 13-17 may nadfc Pharmaceutical Product Working Group 2013Sekretariat Gabungan Perusahaan Farmasi Indonesia, Jl Angkasa No 20 A Kemayoran Jakarta 10620Phone: +62 21 420 3040, Fax : +62 21 420 3047, 420 3048, Email : sekretariatgpfi@yahoo.com Official website : www.20thaccsq-ppwg.com REGISTRATION FORM To register to the Seminar, please return this form duly completed registration form before Tuesday April 30rd, 2013 by Fax. to: +62 21 420 3047 / +62 21 420 3048 or copy scan and email to: sekretariatgpfi@yahoo.com, with Contact Person, Mr Abdul Muid or online through www.20thaccsq-ppwg.com REGISTRATION Information (please type clearly using capital letters and use separate registration form for each person) Full Name : (Mr / Mrs / Ms /Dr) Delegation Country : Nationality : Organization/Company Office Address : •Postal Code : •State : •Phone : •Country : •Facsimile : •Mobile : E-mail Address : Travel Schedule : •Arrival Date : •Arrival Time : •Departure Date : •Departure Time : REGISTRATION Fees Please tick accordingly, Registration Fee is inclusive of lunch, tea breaks, meeting materials, opening ceremony and gala dinner. This does not include the cost of accommodation and travel expenses. Official Designation Registration Free Attendance for Government Delegate Industry as Observer Mr / Ms / Mdm / Dr / Prof  Chair of ACCSQ-PPWG, Free (1) Seminar Before 30 April Before 30 April only Rp. 1.500.000,- / Rp. 1.500.000,- /  Co- chair of ACCSQ-PPWG, Free (1) US$ 160 US$ 160  ASEAN Secretariat, Free (2)  Head of Delegation, Free (1) After 30 April After 30 April  Government Delegates, Free (3) Rp. 2.000.000.- / Rp. 2.000.000.- / (with HOD approval) US$ 210 US$ 210 Seminar + Before 30 April Before 30 April PPWG Rp. 5.300.000,- / Rp. 6.500.000,- / Meeting US$ 550 US$ 680 After 30 April After 30 April Rp. 5.800.000.- / Rp. 7.000.000.- / US$ 600 US$ 730
  2. 20 PPWG nUSA DUA the th ACCSQ bali ASEAN CONSULTATIVE COMMITTEE FOR STANDARDS AND QUALITY 13-17 may nadfc Pharmaceutical Product Working Group 2013Sekretariat Gabungan Perusahaan Farmasi Indonesia, Jl Angkasa No 20 A Kemayoran Jakarta 10620Phone: +62 21 420 3040, Fax : +62 21 420 3047, 420 3048, Email : sekretariatgpfi@yahoo.com Official website : www.20thaccsq-ppwg.com pAYMENT mETHOD Can be made via bank transfer payable to: Bank Name : Bank Central Asia Swift Code : CENAIDJA In USD Account Name : GP Farmasi Indonesia Account Number : 684.028.0029 Bank Address : BCA KCP. KemTower Jl. Landas Pacu Barat Blok B-10 Kav. 2 Jakarta 10610 In Rupiah Account Name : GP Farmasi Indonesia Account Number : 001.310.5160 Bank Address : BCA KCP. Jembatan Merah Jl. Mangga Besar No. 177C Jakarta 11180 • Note that Registration Fee is net and does not include sending bank’s transfer charges. • Please send scanned copy of your deposit slip with your complete name through Fax: +62 21 420 3047, 420 3048 e-mail : sekretariatgpfi@yahoo.com, with cc to email : standarptpkrt@pom.go.id Important Notes  Please ensure your registration form has been completed and duly signed before forwarding to the Meeting Secretariat.  The latest Registration is on May 9, 2013, at 4 pm local time.  You are registered after payment is recieved and confirmation of registration will be issued by email or fax. Please state your email address and fax number clearly in the form.  For inquiries, you may get in touch with: Mr. Abdul Muid through : email sekretariatgpfi@yahoo.com, Fax: +62 21 420 3047, +62 21 420 3048 with cc to: The National Agency of Drug and Food Control (NADFC), Email : standarptpkrt@pom.go.id. Signature Date dd mm yy

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