9MSH2011 Registration Form

1. 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 : 9msh2011@gmail.com
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.