23rd-24th May 2015
Singapore
Delegate's Particulars (Complete in BLOCK LETTERS )
Title
Surname
Prof
Dr
Mr
Ms
Mrs
Non-Vegetarian
Vegetarian: Chinese | Indian
MCR No. (for local only)
Given Name
Name on Certificate
Speciality
Designation
Email
Contact No
Years of Training
1
2
3
4
5
Institution Details
Institution
Department
Mailing Adress
Postal Code
Country
Telephone
City/ State
Program Registration
Early (23rd & 24th)
Regular (23rd & 24th)
One Day (23rd)
Half Day (23rd OR 24th)
Category
Ends at 3rd Apr 2015
Doctors
SGD300
SGD350
SGD200
SGD100
Allied Heath
SGD150
SGD200
SGD100
SGD50
Ends at 15th May 2015
(Radiographers/ Technologists)
*All prices stated above are inclusive of GST.
For half day, please tick and circle one: 23rd
AM / PM
24th
AM / PM
Terms of payment
● All payment must be made in Singapore Dollars (SGD). Payments can be made by cheque/ cash/ credit card/ bank draft/
telegraphic transfer and should be made nett of all bank charges (local and oversea) and commissions.
● Registration will only be valid upon full payment.
● For bank and telegraphic transfer, please provide a copy of the proof of payment in the event that the registration fees were
not credited to the Workshop account on time.
Payment Options
Cash (local registrants)
SGD
Cheque (local registrants)
Singapore cheques only
Cheque No
, Bank name
for SGD
payable to "National University Hospital (S) Pte Ltd" is enclosed.
Please write "RadioPath 2015 May 2015" on the back of the cheque and your name and contact number, as applicable.
RadioPath 2015
23rd-24th May 2015
Singapore
Bank Draft / Telegraphic Transfer (overseas registrants)
I have remitted SGD
through
Beneficiary's Name : National University Hospital (S) Pte Ltd
Beneficiary's Account No: 0-820551-036
Beneficiary's Bank: Citibank N.A.
SWIFT Code: CITISGSG
Branch code: 001
Bank Code: 7214
I have stated that the payment is for RadioPath 2015 May 2015
(Bank name) to account listed below:
Please indicate Registrant Name, and Contact Number clearly, Upon completion of the transfer, please email a copy of remittance
advice with your name to the Secretariat at [email protected] for tracking purposes.
Credit Card Authorization
I hereby authorize payment for registration fee of SGD ___________
Credit Card to Guarantee: AMEX / VISA / MASTERCARD / DINERS (please select)
Cardholder Name:
Credit Card Number:
Expiry date:
m m y
y
Signature (as per credit card):
Credit card must be presented on the date of event for verification purposes.
Instruction to NUH Finance: To credit to fund no: NBDT04DDIS02
Cancellation Policy
There will be no refund of registration fee for cancellations.
Please send the completed registration form by mail (with cheque if applicable) to:
Attn: Julia Ong
National University Hospital
Department of Diagnostic Imaging @ Main Building Level 2
5 Lower Kent Ridge Road, Singapore 119074
Enquiries
Email: [email protected]
Information
Website: http://medicine.nus.edu.sg/meddnr/radiopath2015/
Accomodation Options
Please refer to the following websites for hotels search in Singapore and liase directly with them.
http://www.asiatravel.com/singapore.html
http://www.asiarooms.com/en/singapore/singapore.html
http://www.agoda.com/asia/singapore/singapore.html
http://www.booking.com/country/sg.en.html
http://www.expedia.com.sg/Singapore-Hotels.d180027.Travel-Guide-Hotels
RadioPath 2015