Parenteral and Enteral Nutrition Society of Malaysia (PENSMA) 2012

14th - 16th June, 2012

Shangri-La's Rasa Sayang Resort and Spa, Penang

Registration Form
Personal Particulars
Title: * Prof Dr Dato' Datin Mr Mrs Ms
Full Name:*
Name on Badge: (Limited to 15 alphabets)
Institution:*
Correspondence Address:*
State/Province:*
Postcode:*
Country:*
Telephone:* (Please include country code)
Fax:
Email:*
Remarks:

Registration Fees
Category* On or Before
14 April 2012		 After
14 April 2012		 Amount
Local Delegate PENSMA Member RM500 RM550
Non-PENSMA Member RM600 RM650
Student RM450 RM500
Overseas Delegate USD400 USD450
TOTAL

Bank Details:

Name of Account: Parenteral & Enteral Nutrition Society of Malaysia
Account No: 1265-0000376-05-9
Bank: CIMB Bank Berhad, Jalan Gasing, 111 & 113 Jalan Gasing, 46000 Petaling Jaya
Swift code: CIBBMYKL


Mode of Payment
I will pay online now
Credit Card
I will pay offline by
Malaysian Government Local Purchase Order
LPO No:
Cheque
Bank:
Cheque No:
Cash
Telegraphic Transfer
Company sponsored
Company:





CONGRESS SECRETARIAT

PENSMA 2012
G-1 Medical Academies of Malaysia
210 Jalan Tun Razak
50400 Kuala Lumpur, Malaysia
Fax : 603-4023 8100