Registration Form

Title: Name: Hospital/Institution: Address: Postal Code: City: Phone: IC No: Designation: Dietry Needs/Preference: Vegetarian Date: Non-vegetarian State: Email:
(As per ID Card)

Health Care Seminar 2012 Communications &Quality

If sponsored by company, kindly fill-up the following details: Name of Company: Contact Person: Phone: Email:

PAYMENT
Cheques/bank drafts/postal orders should made payable to IJN COLLEGE SDN BHD For telegraphic transfer (T.T), kindly make payment to Swift Code: Account Holder: Address: MBBEMYKLA IJN COLLEGE SDN BHD MALAYAN BANKING BERHAD, JALAN RAJA MUDA BRANCH, 50300 KUALA LUMPUR 5640 9820 4432

Registrati

on Fees

RM300

8 March

Account No:

2012

Please fax a copy of the cheque/TT/bank draft/postal order with a copy of the registration slip to +603 26006226

Auditorium IJN