Welcome Symposium Registration General Information Social
Program 		Contact

Foreign Registration Form
Fill the form below, or Download this form for offline registration

    Prof.      PhD.      MD.
    Family Name
    Given Name
    Institution
    Address 1
    Address 2
    City , Zip
    Country
    Phone , Fax
    E-Mail
    Please send me an Invitation for Visa Application,
           My Passport Number is:
          
    I don't need any Invitation for Visa Application, Thanks
       
    Accompany
    Family Name
    Given Name

Participants Before
1 May 2004 		After 1 May 2004
/ Onsite 		Person
number
Foreigners US$. 150 US$. 300 person(s)
Accompanying Person US$. 75 US$. 150 person(s)
Workshop on Cadaveric Dissection (Local and Regional Flaps for the hand) US$. 350 US$. 500 person(s)
Workshop on Cadaveric Dissection (Tendon Transfer) US$. 350 US$. 500 person(s)
Instructional Course US$. 150 US$.250 person(s)
All participants for workshop and course has to be registered in symposium

METHOD OF PAYMENT
CREDIT CARD:

For payment with credit card (visa or master only) please down load the registration form and send via fax to 62-21-31909115 or 55960179 along with the card signature
TRANSFER TO :
Bank Mandiri Cabang RSCM
Account name: Dr. Chaula L. Sukasah
Account No: 122-00-04129576
Address : RS. Cipto Mangunkusumo Jl. Diponegoro No. 71
Jakarta Pusat 10440





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