REGISTRATION FORM 5th BORNEO DENTAL CONGRESS 2014 MDA Eastern Zone

REGISTRATIONFORM
5thBORNEODENTALCONGRESS2014
MDAEasternZone
Scienti icMeeting&TradeExhibition
Venue: Ming Garden Hotel and Residence
20-22th March 2015
PARTICIPANT’S DETAILS (Please complete this form in BLOCK le ers)
Title (Please
):
Professor
Dato
Da n
Dr
Mr
Mrs
Ms
Name : ___________________________________________________________________________________________
(As appears on your Iden ty Card)
Ins tu on:_________________________________________________________________________________________
MDC No.: ________________ (Applicable to Malaysians)
DCR No.:_____________ (Applicable to Singaporeans)
Address: ___________________________________________________________________________________________
_______________________ Postcode: _____________ City: _______________ State: _______________________
Country: _________________ Fax: ______________________
Telephone (Work): _____________________
E-mail: ______________________________________
Telephone (Mobile): _____________________
Special Diet: Vegetarian:
Others (Please specify):_____________________________________
CONGRESS REGISTRATION FEES
Please indicate your registra on (Please
Par cipants
):
Early Registra on
(on/before 1st March 2015)
Late registra on
On-site registra on
MDA/SDA Member
RM 300.00
RM 350.00
RM 400.00
Non-MDA Member
RM 450.00
RM 500.00
RM 550.00
Dental Student
RM 250.00
RM 250.00
RM 250.00
Dental Auxiliary
RM 180.00
RM 200.00
RM 220.00
WORKSHOP REGISTRATION (on 20th March, 2015)
Workshop on Orthodon c
By Dr. Loh Kai Woh
Workshop: Topic: TBA
RM450.00 (on/before 1st March 2015)
RM550.00 (on-site registra on)
GRAND TOTAL: RM_________________
100
STUDENT ID VERIFICATION
I cer fy that I am a full me undergraduate student, and hence enabling me to enjoy the ‘Dental Student’ conference
fee rate.
Name of Ins tu on:
Head of Department:
95
75
25
5
Authorized Signature:
Official Stamp of Ins tu on and Date :
0
PAYMENT, REGISTRATION AN D CANCELLATION POLICY
Please make bank dra / cheque in Ringgit Malaysia (RM) made payable to:
MALAYSIAN DENTAL ASSOCIATION EASTERN ZONE
Name of Bank:
Branch:
Account Payee:
Account Number:
PUBLIC BANK BERHAD
Jalan Tuanku Osman, Sibu
MALAYSIAN DENTAL ASSOCIATION EASTERN ZONE
3161261934
Bank Dra / Cheque Number: ……………………………………………….. for amount RM: ……………………….
Credit Card Number: ………………………………………………………………
VISA
MASTERCARD
Card Expiry Date: ……………………………………………………………………
Name as appeared on the card: …………………………………………………………………………………………………………….
Please deduct RM: ………………………………………………………………
Signature: …………………………………………………………………………… Date: ……………………………………………………….
Correspondence Address:
MDA Eastern Zone,
DG-15, Ground Floor, Block Daisy, Indah Court,
Jalan Tuaran, 88400 Likas, Kota Kinabalu, Sabah
Fax: 088-215546 (A en on Dr Leong Kei Joe)
Email: kjleong18@hotmail.com
If you bank in directly, please fax the bank-in slip or email the scanned copy to us together with par cipant’s name
Registra on can also be made on line through the MDA website.
REGISTRATION POLICY:
1. For credit card transac on, 2.5% of the amount payable shall be added to cover for bank charges.
2. Your registra on will be valid when paymen t is received in full by the organizer.
3. The organizer reserve the right to amend any part of the programme without giving prior no ce should the need arise.
4. The organizer reserve the right to cancel the conference or any part thereof without prior no ce in the event of acts of
God, fire, acts of government, terrorism, war or any other event beyond the control of the organizer.
5. For onsite registra on, ONLY payment by cheque and cash in Ringgit Malaysia (RM) will be accepted.
6. Please note that a separate registra on form must be used for each par cipant.
7. Delegates who wish to a end the hands on workshop must prior be FULLY registered for the main congress.
CANCELLATION POLICY:
1. All cancella ons MUST be informed to MDA Eastern Zone Secretariat in wri ng. Fees will be refunded according to the
following schedule:
Cancella on
Penalty charged
Refund amount
On or before 1/03/2015
50% of registra on fees
50% of fees paid
A er 6/3/2015
100% of registra on fees
Nil
2. No replacement will be accepted.
3. Refund will be made ne of bank charges and administra ve charges.
4. Pease allow up to 60 days for refund processing a er the event.
100
95
75
25
5
0