Registration & Payment Form

Registration & Payment Form

Registration and Payment Form for Training Course, Seminar, Conference and other Educational Programme

 

Applicant Particulars

Title :  Dr    Prof    Mr    Miss    Mdm   

Name : (required)

NRIC No. or Passort No. : (required)

Professional Qualifications : (required)

Name of Clinic, Company or Centre Representing ( if applicable ) :

Correspondence address :

Address Line 1 : (required)

Address Line 2 :

City : (required)

State : (required)

Postcode : (required)

Country : (required)

Tel : (required)

Fax :

Handphone :

Email Address : (required)

 

Payment for :

Name of Training Course / Seminar / Conference / Educational Program : (required)

Venue :

Date of programme ( YYYY-MM-DD ) : (required)

Fees Payable (RM) : (required)

 

Accomodation :

if require please specify date of check in and check out and other requests.

Accomodation Fees (RM) :

Total Amount Payable (RM) :

 

Payment method :

To be made upon submission

 By Cheque Deposit    By Interbank Online Transfer   

Name of Account Holder : Persatuan Perubatan Integratif Malaysia

Name of Bank : Alliance Bank Malaysia Berhad

Bank Account No. : 141760010054697

Bank SWIFT Code : MFBBMYKL

Amount : RM

Please email Cheque Deposit Slip to info@integrativemedicinemalaysia.org or by fax.

Browse scanned cheque / bank in slip : ( max. file size limit to 2MB & only allow format pdf, docx, txt, csv, jpg, png and gif )

 

Additional request if any :

Fees paid are not refundable or transferable. By checking this box, I agreed to the terms and conditions.