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 Early BirthUp to
1 May 2004 		After
1 May -
31 August 2004 		After
1 September 2004
/ Onsite 		Person
number
Delegate US$200 US$300 US$400
Workshop (Certified by APSIC) US$150 US$200 US$300
If participants register for workshop and symposium, he/she will entitle to have 10% discount

HOTEL Price / Night(net) Check in Date
(dd/mm/yyyy) 		Check out Date
(dd/mm/yyyy) 		Total Nights Number of
Room
InterContinental MidPlaza USD 135 room(s)
A deposit of US$135 per room is required for all bookings, deposit will not be refundable.



METHOD OF PAYMENT :
CREDIT CARD :

For payment with credit card (visa or master only) please down load the registration form and send to Ferah Fax no: 62-21-3919653 or 62-21-559-601-79 along with the card signature
TRANSFER TO :
Bank Mandiri Cab. RSCM
Account Name: Dr. Djoko Widodo / Ibu Betty
Account Number: 122-00-0411727-4
Bank address: RSCM Jl. Diponegoro Kav. 71, Jakarta Pusat 10430, Indonesia
Bank charges will be borne by participants


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