REGISTRATION FORM 13th PENANG DENTAL CONGRESS Venue: Bayview Beach Resort, Batu Feringghi, Penang Date: 17 October 2014 (Pre-Congress Hands-on) 18-19 October 2014 (Main Congress) 18 October 2014 (Dental Nurse and DSA Symposium) Malaysian Dental Association Northern Zone PARTICIPANT’S DETAILS (Please complete this form in BLOCK letters) Title (Please ): Professor  Dato  Datin  Dr  Mr  Mrs  Ms  Name : ______________________________________________________________________________ Institution:________________________________ (As appears on your Identity Card) MDC No: _____________________ (Applicable to Malaysians) IC No: ______________________________(Applicable to Malaysians) DCR No:_______________(Applicable to Singaporeans) Address: _____________________________________________________________________________ ___________________ Postcode: _________ Country: _______________ City: ________________ Fax: _______________ E-mail: ______________________________________ Special Diet: Vegetarian:  State: _______________ Telephone (Work) : _____________________ Telephone (Mobile): _____________________ Others (Please specify):_____________________________________ CONFERENCE REGISTRATION FEES Please indicate your registration (Please ): Early Registration Participants (on/before 1/10/2014) Late Registration (after 1/10/2014) On-site registration MDA/SDA Member RM 300  RM 400  RM 450  Non-MDA Member RM 500  RM 600  RM 650  Dental Student RM 200  RM 200  RM 250  Foreign Dentist RM 500  RM 600  RM 650  Nurse/ DSA RM 100  RM 100  RM 100  SUBTOTAL(A): RM_____________ HANDS-ON WORKSHOP (17/10/2014) (limited to 24 pax) (Please ): 1. Dr Karthikeyan Ponnusami Pre Fabricated Composite Veneering System (Half day) ……… RM200  SUBTOTAL(B): RM_____________ MASTER CLASS (17/10/2014) (limited to 30 pax) (Please ): 1. Dr Chris Chang Topic 1: Simplify Your Orthodontic Treatment Topic 2: Class II Correction Topic 3: Class III Correction Topic 4: Complex Cases Made Easy (Full day) ……… RM1000  SUBTOTAL(C): RM_____________ GRAND TOTAL(A+B+C): RM____________ STUDENT ID VERIFICATION I certify that I am a full time undergraduate student, and hence enabling me to enjoy the ‘Dental Student’ conference fee rate. Name of Institution: ____________________________________ Head of Department: _____________________ Authorized Signature: _____________________ ______________________________ Official Stamp of Institution and Date PAYMENT AND CANCELLATION POLICY 1. Please make bank draft/cheque in Ringgit Malaysia (RM) payable to “MALAYSIAN DENTAL ASSOCIATION NORTHERN ZONE”. Registration will be valid upon receipt of full payment. Bank Draft/Cheque Number: ______________________for the amount RM____________________ 2. Online registration and payment can be made through MDA website at www.mda.org.my. CANCELLATIONS: 1. All cancellations MUST be informed to MDA Northern Zone Secretariat in writing. Fees will be refunded according to the following schedule: Cancellation Penalty charged Refund amount On or before 10/09/2014 50% of registration fees 50% of fees paid After 10/09/2014 100% of registration fees Nil 2. Refund will only be made one month after the congress. The Disclaimer to Registration Policy: A) Please note that a separate registration form must be used for each participant. B) The organizing committee reserves the right to change or cancel the programme without prior notice if circumstances dictate. C) Dental student fee is only applicable to Undergraduate students. D) Registration will only considered as valid when full payment is received. Delegates who pay onsite will be considered as onsite registration in which onsite registration fees apply. E) Registration counter for main congress will ONLY be open on 18/10/2014 (Saturday), 8am-3pm. F) Certificate of attendance will ONLY be issued on 19/10/2014 (Sunday) from 2pm onwards, postage of certificates will not be entertained. G) Delegates who wish to attend hands-on workshop/master class must register both the main congress and the hands-on workshop/master class. H) Online registration will be closed on 13/10/2014 (2359GMT+8) Please mail completed registration form to: Malaysian Dental Association Northern Zone, 15A, 1ST Floor, Jalan Tembikai, Taman Mutiara, 14000 Bukit Mertajam, Seberang Perai, Malaysia. For any enquiries, please email us at: [email protected]