REGISTRATIONFORM 5thBORNEODENTALCONGRESS2014 MDAEasternZone Scienti icMeeting&TradeExhibition Venue: Ming Garden Hotel and Residence 20-22th March 2015 PARTICIPANT’S DETAILS (Please complete this form in BLOCK le ers) Title (Please ): Professor Dato Da n Dr Mr Mrs Ms Name : ___________________________________________________________________________________________ (As appears on your Iden ty Card) Ins tu on:_________________________________________________________________________________________ MDC No.: ________________ (Applicable to Malaysians) DCR No.:_____________ (Applicable to Singaporeans) Address: ___________________________________________________________________________________________ _______________________ Postcode: _____________ City: _______________ State: _______________________ Country: _________________ Fax: ______________________ Telephone (Work): _____________________ E-mail: ______________________________________ Telephone (Mobile): _____________________ Special Diet: Vegetarian: Others (Please specify):_____________________________________ CONGRESS REGISTRATION FEES Please indicate your registra on (Please Par cipants ): Early Registra on (on/before 1st March 2015) Late registra on On-site registra on MDA/SDA Member RM 300.00 RM 350.00 RM 400.00 Non-MDA Member RM 450.00 RM 500.00 RM 550.00 Dental Student RM 250.00 RM 250.00 RM 250.00 Dental Auxiliary RM 180.00 RM 200.00 RM 220.00 WORKSHOP REGISTRATION (on 20th March, 2015) Workshop on Orthodon c By Dr. Loh Kai Woh Workshop: Topic: TBA RM450.00 (on/before 1st March 2015) RM550.00 (on-site registra on) GRAND TOTAL: RM_________________ 100 STUDENT ID VERIFICATION I cer fy that I am a full me undergraduate student, and hence enabling me to enjoy the ‘Dental Student’ conference fee rate. Name of Ins tu on: Head of Department: 95 75 25 5 Authorized Signature: Oﬃcial Stamp of Ins tu on and Date : 0 PAYMENT, REGISTRATION AN D CANCELLATION POLICY Please make bank dra / cheque in Ringgit Malaysia (RM) made payable to: MALAYSIAN DENTAL ASSOCIATION EASTERN ZONE Name of Bank: Branch: Account Payee: Account Number: PUBLIC BANK BERHAD Jalan Tuanku Osman, Sibu MALAYSIAN DENTAL ASSOCIATION EASTERN ZONE 3161261934 Bank Dra / Cheque Number: ……………………………………………….. for amount RM: ………………………. Credit Card Number: ……………………………………………………………… VISA MASTERCARD Card Expiry Date: …………………………………………………………………… Name as appeared on the card: ……………………………………………………………………………………………………………. Please deduct RM: ……………………………………………………………… Signature: …………………………………………………………………………… Date: ………………………………………………………. Correspondence Address: MDA Eastern Zone, DG-15, Ground Floor, Block Daisy, Indah Court, Jalan Tuaran, 88400 Likas, Kota Kinabalu, Sabah Fax: 088-215546 (A en on Dr Leong Kei Joe) Email: kjleong18@hotmail.com If you bank in directly, please fax the bank-in slip or email the scanned copy to us together with par cipant’s name Registra on can also be made on line through the MDA website. REGISTRATION POLICY: 1. For credit card transac on, 2.5% of the amount payable shall be added to cover for bank charges. 2. Your registra on will be valid when paymen t is received in full by the organizer. 3. The organizer reserve the right to amend any part of the programme without giving prior no ce should the need arise. 4. The organizer reserve the right to cancel the conference or any part thereof without prior no ce in the event of acts of God, ﬁre, acts of government, terrorism, war or any other event beyond the control of the organizer. 5. For onsite registra on, ONLY payment by cheque and cash in Ringgit Malaysia (RM) will be accepted. 6. Please note that a separate registra on form must be used for each par cipant. 7. Delegates who wish to a end the hands on workshop must prior be FULLY registered for the main congress. CANCELLATION POLICY: 1. All cancella ons MUST be informed to MDA Eastern Zone Secretariat in wri ng. Fees will be refunded according to the following schedule: Cancella on Penalty charged Refund amount On or before 1/03/2015 50% of registra on fees 50% of fees paid A er 6/3/2015 100% of registra on fees Nil 2. No replacement will be accepted. 3. Refund will be made ne of bank charges and administra ve charges. 4. Pease allow up to 60 days for refund processing a er the event. 100 95 75 25 5 0