| REGISTRATION FORM |
| A. Personal Details |
| Title :
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| Surname : |
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| Given name : |
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| Name on badge: |
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| Institution/Company : |
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| Address : |
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| Postal Code : |
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| Tel : |
(Home) (Country-Area-Number) |
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(Office) (Country-Area-Number) |
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| Email : |
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Pleas check your e-mail address very carefully. Confirmation will be sent to this address. |
| Food : |
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Please specify |
| Please indicate a type of food you prefer during the congress : |
| B. Conference Details
Early bird
Regular Registration |
| Categories |
Payment received by,June 30, 2008
Payment received by,July 1, 2008 |
| Member (Asia4safehandling/ APOPS) |
International
Participant |
US $ 200
US $ 250 |
| Local Participant |
Baht 3,000
Baht 3,500 |
| Non-member |
International
Participant |
US $ 250
US $ 300 |
| Local Participant |
Baht 3,500
Baht 4,000 |
| Student |
International
Participant |
US $ 150
US $ 200 |
| Local Participant |
Baht 2,000
Baht 2,500 |
| Accompanying persons |
International
Participant |
US $ 150
US $ 200 |
| Local Participant |
Baht 2,000
Baht 2,500 |
| Accompanying person (s) (maximum two) |
| 1.Last/Surname : |
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| First name :
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| 2.Last/Surname : |
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| First name :
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| Total Payments US $ |
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| C. Mode of Payment |
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using Card |
| - Card Type : |
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| - Card Holder's name : |
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| - Card Number : |
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| - CVC Code : |
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| - Card Expiry : |
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(Month - Year) |
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By Direct bank transfer / ATM |
1) Name of beneficiary: APOPC
2) Beneficiary Address & Tel Number:
The 2nd Asia Pacific Oncology Pharmacy Congress (APOPC)
Secretariat Office, Faculty of Pharmaceutical Sciences
Khon Kaen University, Thailand
Tel: +66 (0)4320 3479
3) Bank Name:
Siam Commercial Bank Company Limited, into the conference bank account at
Siam Commercial Bank Company Limited (Khon Kaen University Branch),
4) Branch Name, Address & Tel Number:
123/900 MU 16 Mittraphab Road, TB.Naimuang, AP.Muang, Khon Kaen, 40002, Thailand.
Tel: +66(0)4323-6977 Fax +66(0)4323-8788
5) Bank SWIFT Code: SICOTHBK
6) Account No: 551-2-95342-2
(Please enclose the receipt of payment from the bank when you send in your registration form)
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1. Written notice of cancellation must be received bi the Congress
Secretariat by 31 August 2008
2. An administrative charge of 25% will be deducted from the relevant
fee paid.
3. The Organizing Committee regrets it cannot entertain refunds or
Cancellations after 31 August 2008
4. All refunds will be issued after 10 October 2008 |
sent to you when you complete this online submission.
For those paying by direct bank transfer please send your receipt
together with a copy of this email to APOPC Secretariat address below :
Thongkum Vongprajan
THE SECOND ASIA-PACIFIC ONCOLOGY PHARMACY CONGRESS
Faculty of Pharmaceutical Sciences, Khon Kaen University, 40002 Thailand
Office The Dean Tel. : +66 (0)4320 3479 Ext. 401/480
Fax. : +66 (0)4320 2379 Email : apopc08.info@gmail.com |
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