PLEASE FILL IN THIS FORM WITH CAPITAL BLOCK

       

FAMILY NAME
GIVEN NAME
INSTITUTION
ADDRESS
CITY COUNTRY ZIP
   
PHONE   FAX  
EMAIL
REGISTRATION FEE
REGISTRATION FEE
UP to September 15th, 2010
After September 15th, 2010
Specialist USD 350 USD 400
Student /Trainee * USD 250 USD 300
Accompanying Person USD 150
*supporting letter is required
Total Registration Fee USD
 
ACCOMODATION

Hotel / Room Type

Rate/Night

Number of room booked

Check in date
(dd/mm/yy)

Check Out date
(dd/mm/yy)

Total Nights

Grand Hyatt Bali ***** (FULLY BOOKED from date 9 Agustus 2010)

> Garden room

USD 190

Westin Resort ***** (FULLY BOOKED from date 22 Agustus 2010)

> Classic Garden

USD 190

Nusa Dua Beach *****

> Superior Room

USD 140

Novotel Nusa Dua *****

> Deluxe Room

USD 130

The Grand Bali ****

> Deluxe Room

USD 110

Putri Bali **** (FULLY BOOKED from date 3 September 2010)

> ROH

USD 70

Melia Bali *****

> Deluxe

USD 160

> Duplex

USD 205

 
Total Accomodation Cost USD
 
Total Registration and Accomodation USD
 
PAYMENT METHODS
Transfer via following acount:
Bank name :
Bank MANDIRI, KCP Jakarta RSCM
Account Name :
dr. RAHAJUNINGSIH DHARMA
Account Number : 122-00-0532801-1
Swift Code : BMRIIDJA
Bank charges will be borne by participants
 I authorize payment by credit card
(Visa and Mastercard only)
Bank charges of 5% of the total
amount will be borne by participant
Card Members Name: Card No.
Expired Date: Signature: Date:
 

Message:

File Attachment: * Upload Your payment print out. (file type : jpg)