REGISTRATION FORM 16th Dubai World Dermatology and Laser Conference & Exhibition 12th - 14th April | Dubai International Convention & Exhibition Centre Email*: Prefix: Prof. Dr. Mr. Mrs. Ms. (Please write name in BLOCK letters) Note: The name mentioned below will appear the same in the Certificate of Attendance First Name*: Last Name*: Job Title*: Company*: Address Line 1*: City*: Country*: Work Phone*: Fax: P.O.Box*: Mobile Phone*: * Mandatory Early Bird Registration UNTIL December 31, 2015 Pre-Registration Registration February 28, 2016 April 1, 2016 p Pre-Conference Course (8-11 April 2016) - - - - - AED 3,150 AED 3,350 p Cosmetic Course (11 April 2016) - - - - - - - - - - AED 3,030 AED 2,030 AED 2,220 Select [R] your Registration Dermatology & Dermatopathology Skin Fillers & Botox p Conference (12-14 April 2016) Entitlements: AED 1,850 • Attendance Certificate • Conference or Course Materials UNTIL AFTER • Verification of Participation (Credit Points) • Lunch and Coffee Break Together we support research By registering, you are supporting “Al Jalila Foundation for Medical Education & Research Support” NOTE: • The participants should understand that the speakers provide only their perspective of any new techniques and procedures; and potential risks might be possible if it is applied into clinical practice without sufficient education, training and /or supervision. • If VISA is required, kindly send the Visa Application Form and a Valid Passport Copy along the registration confirmation. Form can be downloaded from www.index.ae/visa. PAYMENT can be made either by cash or credit card to: INDEX® Conferences & Exhibitions Organisation Est. PAYMENT DETAILS q Cash q Visa q Master Card Credit Card No. Expiry Date MONTH YEAR Name on Card_________________________________________________________________________________________________ AUTHORIZATION NOTE Please debit my credit card with an amount of AED........................ I, ...............................................................................................the card holder will honor this transaction and not hold INDEX® Conferences & Exhibitions Organisation Est. responsible if the credit card number has been compromised. CANCELLATION POLICY I understand that the above mentioned charges per registration will be non-refundable. Date: _________ /_________ / ____________ Signature:______________________________ For Registration, contact: Tel: +971 4 3624717 | Fax: +971 4 3624718 | [email protected]