Registration Form Please [ √ ] where applicable Mr. Mrs. Ms. ____________________________________________________________________ (Title, if any) Name: IC No./Passport No.: Email: Tel: Fax: Mobile: Organisation: Mailing Address: Country: Do You Require A Vegetarian Meal? Yes No LECTURE SERIES 2014 FEE Student / local NGO : RM 50 Government : RM 150 Corporate : RM 250 International / INGO : RM 380 PAYMENT METHOD: Online registration & payment is available at www.mercy.org.my or payment must be made and received before the event, by one of the following methods: CIMB BANK - Banktransfer/ Online Transfer/ Cheque Account Name: MALAYSIAN MEDICAL RELIEF SOCIETY Account No: 8000-7929-08 ABA Swift Code: CIBBMYKL Account Bank and Address: CIMB BANK No. 4, Jalan Langgak Golf, Off Jalan Tun Razak, 55000 Kuala Lumpur, Malaysia. Fax Number: +603 2142 1992 L.O. is acceptable for Malaysian Government Departments. NOTE: 1. For bank draft, request for clearing at a local bank in Kuala Lumpur, Malaysia. 2. Attach a copy of registration form with the bank draft/cheque. 3. Fax a copy of this form to +603 2142 1992 or email to [email protected] or [email protected] to register (include proof payment) OR send payment and form to the following address: MERCY Malaysia, No. 4, Jalan Langgak Golf, Off Jalan Tun Razak, 55000 Kuala Lumpur, Malaysia. TERMS AND CONDITIONS OF REGISTRATION It is the responsibility of the Delegates to ensure the Organisers received the payment in full without any deduction for bank charges. Payment information 1. All payments MUST be made and confirmed by/before 17 November 2014. Registration is not considered complete until payment is received. 2. Participant will be issued a receipt upon confirmation of payment. Receipt can be collected during the conference. 3. Fees are payable in the stated currencies only. Cancellations and Substitutions 1. Request for cancellation will not be entertained. 2. Attendee substitutions may be made from the same organisation and must be submitted in writing to [email protected] or [email protected] 5 days before the conference event. Exclusion The fee does not include accommodation, travel costs to and from the Lecture Series 2014 venue and other unspecified taxes, if any. Limited Liability In the event of cancellation of Lecture Series 2014 our liability will be limited only to full repayment of fees paid. I agree to be bound by the “Sultan Nazrin Shah Lecture Series 2014” conference Terms and Conditions of Registration. _______________________ Signature ________________ Date