REGISTRATION FORM 13 PENANG DENTAL CONGRESS

REGISTRATION FORM
13th PENANG DENTAL CONGRESS
Venue: Bayview Beach Resort, Batu Feringghi, Penang
Date: 17 October 2014 (Pre-Congress Hands-on)
18-19 October 2014 (Main Congress)
18 October 2014 (Dental Nurse and DSA Symposium)
Malaysian Dental Association
Northern Zone
PARTICIPANT’S DETAILS (Please complete this form in BLOCK letters)
Title (Please
):
Professor 
Dato 
Datin 
Dr 
Mr 
Mrs 
Ms 
Name : ______________________________________________________________________________
Institution:________________________________
(As appears on your Identity Card)
MDC No: _____________________ (Applicable to Malaysians)
IC No: ______________________________(Applicable to Malaysians)
DCR No:_______________(Applicable to Singaporeans)
Address: _____________________________________________________________________________
___________________
Postcode: _________
Country: _______________
City: ________________
Fax: _______________
E-mail: ______________________________________
Special Diet:
Vegetarian: 
State: _______________
Telephone (Work) : _____________________
Telephone (Mobile): _____________________
Others (Please specify):_____________________________________
CONFERENCE REGISTRATION FEES
Please indicate your registration (Please ):
Early Registration
Participants
(on/before 1/10/2014)
Late Registration
(after 1/10/2014)
On-site registration
MDA/SDA Member
RM 300 
RM 400 
RM 450 
Non-MDA Member
RM 500 
RM 600 
RM 650 
Dental Student
RM 200 
RM 200 
RM 250 
Foreign Dentist
RM 500 
RM 600 
RM 650 
Nurse/ DSA
RM 100 
RM 100 
RM 100 
SUBTOTAL(A): RM_____________
HANDS-ON WORKSHOP (17/10/2014) (limited to 24 pax)
(Please
):
1. Dr Karthikeyan Ponnusami
Pre Fabricated Composite Veneering System
(Half day) ……… RM200

SUBTOTAL(B): RM_____________
MASTER CLASS (17/10/2014) (limited to 30 pax)
(Please
):
1. Dr Chris Chang
Topic 1: Simplify Your Orthodontic Treatment
Topic 2: Class II Correction
Topic 3: Class III Correction
Topic 4: Complex Cases Made Easy
(Full day) ……… RM1000

SUBTOTAL(C): RM_____________
GRAND TOTAL(A+B+C): RM____________
STUDENT ID VERIFICATION
I certify that I am a full time undergraduate student, and hence enabling me to enjoy the ‘Dental Student’
conference fee rate. Name of Institution: ____________________________________
Head of Department: _____________________
Authorized Signature: _____________________
______________________________
Official Stamp of Institution and Date
PAYMENT AND CANCELLATION POLICY
1. Please make bank draft/cheque in Ringgit Malaysia (RM) payable to “MALAYSIAN DENTAL ASSOCIATION
NORTHERN ZONE”. Registration will be valid upon receipt of full payment.
Bank Draft/Cheque Number: ______________________for the amount RM____________________
2. Online registration and payment can be made through MDA website at www.mda.org.my.
CANCELLATIONS:
1. All cancellations MUST be informed to MDA Northern Zone Secretariat in writing. Fees will be refunded according
to the following schedule:
Cancellation
Penalty charged
Refund amount
On or before 10/09/2014
50% of registration fees
50% of fees paid
After 10/09/2014
100% of registration fees
Nil
2. Refund will only be made one month after the congress.
The Disclaimer to Registration Policy:
A) Please note that a separate registration form must be used for each participant.
B) The organizing committee reserves the right to change or cancel the programme without prior notice if
circumstances dictate.
C) Dental student fee is only applicable to Undergraduate students.
D) Registration will only considered as valid when full payment is received. Delegates who pay onsite will be
considered as onsite registration in which onsite registration fees apply.
E) Registration counter for main congress will ONLY be open on 18/10/2014 (Saturday), 8am-3pm.
F) Certificate of attendance will ONLY be issued on 19/10/2014 (Sunday) from 2pm onwards, postage of certificates
will not be entertained.
G) Delegates who wish to attend hands-on workshop/master class must register both the main congress and the
hands-on workshop/master class.
H) Online registration will be closed on 13/10/2014 (2359GMT+8)
Please mail completed registration form to:
Malaysian Dental Association Northern Zone,
15A, 1ST Floor, Jalan Tembikai, Taman Mutiara, 14000 Bukit Mertajam, Seberang Perai, Malaysia.
For any enquiries, please email us at: mda.northernzone@gmail.com