MALAYSIAN DIABETES EDUCATORS SOCIETY CONFERENCE 2014REGISTRATION FORM
A. DELEGATE DETAILSProf / Dr / Mr / Mrs / Ms
(Name to be printed on name badge and certificate, please fill in BLOCK LETTERS)

Doctor

Nurse

Pharmacist

DieticianMA

Diabetes Educator

Others:Organisation:

Department:

Address:
Postcode:State:Country:

Telephone:

Ext:

Fax:

E‐mail:Are you Vegetarian:

Yes

Mobile:No

B. REGISTRATION FEES

Please tick ‘√’ where appropriate

Category

Early Bird Registration
On or Before 28th Feb 2014

Normal Registration
After 28th Feb 2014

RM 450

RM 500Non-member (Allied Health)

RM 650

RM 700Non-member (Doctor and PhD)

RM 750

RM 800International Delegate

RM 1000

RM 1200

MDES member (MDES Membership Number:Student (Attach photocopy of student ID)

Day Registration (Please specify date)
25th April 2014
26th April 2014)

RM 300 / day
27th April 2014

a. The registration fee includes admission to all sessions, coffee breaks and lunches ONLY
b. Acceptance of registration is at the sole discretion of the Organising Committee.
Confirmation of registration will be provided in writing only after receipt of full payment.
C. PAYMENT DETAILSALL Payment made payable to MALAYSIAN DIABETES EDUCATORS SOCIETY
Enclosed is my total payment of RM

to be made through: (tick where appropriate)

1. Local Order (for Malaysians Only)

LO Reference No:

2. Cheque No:

Cheque Issuing Bank:

3. Telegraphic Transfer
T.T Reference No:

T.T From (Bank Name)*Important Note: Please scan your TT slip and email to the Secretariat for verification
4. Credit Card
Type of Credit Card:

VisaMaster

AMEX

I authorise Console Communications Sdn Bhd to debit the total amount of RM

from my Credit Card(details provided below) for the registration fees.
Name of Card Holder:

Credit Card Number:

Expiry Date (MM / YY):

Card Issued by (Bank):*CBC / CVC Code:*Visa / Master: The last 3 digit number on the reverse
side of your card.
*AMEX: The 4 digit number on the left / right of your card.

Credit Card Authorised Signature

D. TERMS AND CONDITIONS• All payments must be made in RM. International delegates can make payment by Credit Card or Telegraphic Transfer. Malaysiandelegates can make payment by Local Cheque, Local Order, Credit Card or Telegraphic Transfer.
• Please note that all related bank charges, financial charges or credit card commission (5%) are to be borne by the delegates andare not to be deducted from the fees payable to the Conference.
• Company Cheque (for Malaysian only), Local Order (for Malaysian only), and Telegraphic Transfer is to be made to the following
bank account:
Account name:

MALAYSIAN DIABETES EDUCATORS SOCIETY

Name of bank:

MAYBANK

Account no:5142-5350-9484

Address:

Dataran Maybank Branch, Level 1, Tower A, Dataran Maybank, No. 1, Jalan Maarof, Bangsar, 59000 KL.

SWIFT code:

MBBEMYKL

E. CONFIRMATION• Registration will only be confirmed upon receipt of FULL PAYMENT.
• Upon receipt of the FULL payment, the Secretariat will send you a Confirmation Letter via email.
• Please bring along the Confirmation Letter and present it at the time of Registration at the Conference.

F. CANCELLATION POLICY• Cancellation of registration must be made in writing to the Secretariat. Refunds will only be made after the Conference.
• Cancellation received on or before 1st March 2014: 50% refund• Cancellation received after 1st March 2014: No refund*Paid registration fee is not refundable after the stipulated date for whatever reasons, including failure of obtaining VISA.

Please forward the completed Registration Form to:
SECRETARIAT
c/o Console Communications Sdn Bhd
Suite 12.9, Level 12, Wisma UOA ll, 21, Jalan Pinang 50450 Kuala Lumpur
Tel: +603 2162 0566

I

Fax: +603 2161 6560

Email: marcus@console.com.my

I/C No:acknowledged read, understood and agreed on the above terms and conditions.

Signature:Date:hereby