APAGE 2009 TAIWAN REGISTRATION FORM

Department Code:

1401605500

Authorize No.: ____________

Last Name:

First Name:

Title:

Prof.    Dr.    Miss    Mr.

Nationality:

Passport No:

Institution:

Specialty:

Society:

Email:

 

Country Code

Area Code

Number

Phone:

Fax:

Mobile:

Address for Correspondence:

 

Invoice Title:

I Register to the:                Only PG Courses US$ 0

CONGRESS - Early (Deadline: August 31, 2009)

APAGE Member: US$300

Non APAGE Member: US$350

Trainee, Nurse: US$200

Accompanying person: US$150

PG1+PCW1 US$1,200

PG2+PCW2 US$1,200

PG3+PCW3 US$1,200

 

CONGRESS - Late (Deadline: September 15, 2009)

 APAGE Member: US$350

 Non APAGE Member: US$400

Trainee, Nurse: US$250

 Accompanying person: US$200

 PG1+PCW1 US$1,500

PG2+PCW2 US$1,500

 PG3+PCW3 US$1,500

 

Credit Card Type:

VISA   MASTER   JCB   U CARD

Credit Card NO:

Expiry Date:

/m /y

Swift Code:

Total Amount:

US$

Signature: _______________________   Date: ______ /d ______ /m __________ /y

Your credit card will not be charged directly but will secure your booking.

Your credit card will be charged within the next 72 hours from the amount of the day you fax.

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Check your signature and date before you fax this form.