Document 424677

(Spine Section of APOA)
APSS Myanmar Operative
Spine Course
6th – 8th February
2015
Yangon Orthopaedic Hospital Spine Center, Yangon, Myanmar
REGISTRATION FORM
A: PERSONAL PARTICULARS
Salutation:
q Prof
q A/Prof
q Dr
q Mr
q Mrs
Full Name:
q Ms
Gender:
q Male
q Female
Date of Birth: (Date / Month / Year)
Correspondence Address:
State:
Country:
Postal Code:
Contact Number:
Mobile Number: (Optional)
Facsimile Number:
Email Address:
Are you the APOA/APSS Existing Member?
q
q
Yes
No
Institution:
Specialty:
B: REGISTRATION FEES
Category
Amount Payable (USD)
200 q International Surgeon
q Burmese Surgeon
50 TOTAL (USD) C: PAYMENT
q Credit Card
Credit Card Type
: ______________________________________________________________________________________
Credit Card Number
: _____________________________________________________________________________________
Expiry / Validity
: ____________________________________ Card Security Code (CSC) : _________________________
Details of card use
: _____________________________________________________________________________________
Credit Card Holder’s Name : ___________________________________ Signature : _______________________________________
D: SUGGESTED ACCOMMODATIONS
Kindly contact the below listed hotels to make your own reservation:(1) Hotel Grand United (Ahlone), No. 35, Min Ye KyawSwar Road, Ahlone Township, Yangon, Myanmar, Tel: +95-1-218061~64,
0973048864, Website: http://www.hotelgrandunited.com, Email: [email protected]
(2) Summit Parkview Hotel, No. 350, Ahlone Road, Dagon Township, Yangon, Myanmar, Tel: +95-1-211888, 211966, Fax: +95-1-227990,
227995, Website: http://www.summityangon.com, Email: [email protected] , [email protected]
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(3) Hotel Yangon, 91/93, Corner of Pyay Road and Kabar Aye Pagoda Road, 8 Mile Junction, Mayangone Township, Yangon, Myanmar,
Tel: +95-1-667708, 667688, Fax: +95-1-667752, Website: http://www.hotelyangon.net, Email: [email protected]
(4) Panda Hotel, No. 205, Corner of Wardan Street and Min Ye KyawSwar Road, Lanmadaw Township, Yangon, Myanmar,
Tel: +95-1-212850~3, 229358~61, Fax: +95-1-212854, Website: http://www.myanmarpandahotel.com, Email:
[email protected]
I hereby declare that the information given above is true and genuine.
Signature : _________________________________________________ Date : ___________________________________________
Please complete and return this form before 9th January 2015 (Friday) to:
APSS SECRETARIAT
G-1, Medical Academies of Malaysia, 210, Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia.
TEL: (+603) 4023 4700, 4025 4700 FAX: (+603) 4023 8100 EMAIL: [email protected]
* Any replies received after 9th January 2015 (Friday) will be subject to seats availability !
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