Registration Form

Registration Form
Please [ √ ] where applicable
Mr.
Mrs.
Ms.
____________________________________________________________________ (Title, if any)
Name:
IC No./Passport No.:
Email:
Tel:
Fax:
Mobile:
Organisation:
Mailing Address:
Country:
Do You Require A Vegetarian Meal? Yes
No
LECTURE SERIES 2014 FEE
Student / local NGO
:
RM
50
Government
:
RM 150
Corporate
:
RM 250
International / INGO
:
RM 380
PAYMENT METHOD:
Online registration & payment is available at
www.mercy.org.my or payment must be made and
received before the event, by one of the following
methods:
CIMB BANK - Banktransfer/ Online Transfer/ Cheque
Account Name: MALAYSIAN MEDICAL RELIEF SOCIETY
Account No: 8000-7929-08
ABA Swift Code: CIBBMYKL
Account Bank and Address: CIMB BANK
No. 4, Jalan Langgak Golf, Off Jalan Tun Razak,
55000 Kuala Lumpur, Malaysia.
Fax Number: +603 2142 1992
L.O. is acceptable for Malaysian Government Departments.
NOTE:
1. For bank draft, request for clearing at a local bank in
Kuala Lumpur, Malaysia.
2. Attach a copy of registration form with the bank
draft/cheque.
3. Fax a copy of this form to +603 2142 1992 or email to
[email protected] or [email protected] to
register (include proof payment) OR
send payment and form to the following address:
MERCY Malaysia, No. 4, Jalan Langgak Golf, Off Jalan
Tun Razak, 55000 Kuala Lumpur, Malaysia.
TERMS AND CONDITIONS OF REGISTRATION
It is the responsibility of the Delegates to ensure the
Organisers received the payment in full without any
deduction for bank charges.
Payment information
1. All payments MUST be made and confirmed
by/before 17 November 2014. Registration is not
considered complete until payment is received.
2. Participant will be issued a receipt upon
confirmation of payment. Receipt can be
collected during the conference.
3. Fees are payable in the stated currencies only.
Cancellations and Substitutions
1. Request for cancellation will not be entertained.
2. Attendee substitutions may be made from the
same organisation and must be submitted in writing
to [email protected] or [email protected]
5 days before the conference event.
Exclusion
The fee does not include accommodation, travel
costs to and from the Lecture Series 2014 venue and
other unspecified taxes, if any.
Limited Liability
In the event of cancellation of Lecture Series 2014 our
liability will be limited only to full repayment of fees
paid.
I agree to be bound by the “Sultan Nazrin Shah
Lecture Series 2014” conference Terms and Conditions
of Registration.
_______________________
Signature
________________
Date
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