(Spine Section of APOA) APSS Myanmar Operative Spine Course 6th – 8th February 2015 Yangon Orthopaedic Hospital Spine Center, Yangon, Myanmar REGISTRATION FORM A: PERSONAL PARTICULARS Salutation: q Prof q A/Prof q Dr q Mr q Mrs Full Name: q Ms Gender: q Male q Female Date of Birth: (Date / Month / Year) Correspondence Address: State: Country: Postal Code: Contact Number: Mobile Number: (Optional) Facsimile Number: Email Address: Are you the APOA/APSS Existing Member? q q Yes No Institution: Specialty: B: REGISTRATION FEES Category Amount Payable (USD) 200 q International Surgeon q Burmese Surgeon 50 TOTAL (USD) C: PAYMENT q Credit Card Credit Card Type : ______________________________________________________________________________________ Credit Card Number : _____________________________________________________________________________________ Expiry / Validity : ____________________________________ Card Security Code (CSC) : _________________________ Details of card use : _____________________________________________________________________________________ Credit Card Holder’s Name : ___________________________________ Signature : _______________________________________ D: SUGGESTED ACCOMMODATIONS Kindly contact the below listed hotels to make your own reservation:(1) Hotel Grand United (Ahlone), No. 35, Min Ye KyawSwar Road, Ahlone Township, Yangon, Myanmar, Tel: +95-1-218061~64, 0973048864, Website: http://www.hotelgrandunited.com, Email: [email protected]. (2) Summit Parkview Hotel, No. 350, Ahlone Road, Dagon Township, Yangon, Myanmar, Tel: +95-1-211888, 211966, Fax: +95-1-227990, 227995, Website: http://www.summityangon.com, Email: [email protected] , [email protected]. th (3) Hotel Yangon, 91/93, Corner of Pyay Road and Kabar Aye Pagoda Road, 8 Mile Junction, Mayangone Township, Yangon, Myanmar, Tel: +95-1-667708, 667688, Fax: +95-1-667752, Website: http://www.hotelyangon.net, Email: [email protected]. (4) Panda Hotel, No. 205, Corner of Wardan Street and Min Ye KyawSwar Road, Lanmadaw Township, Yangon, Myanmar, Tel: +95-1-212850~3, 229358~61, Fax: +95-1-212854, Website: http://www.myanmarpandahotel.com, Email: [email protected]. I hereby declare that the information given above is true and genuine. Signature : _________________________________________________ Date : ___________________________________________ Please complete and return this form before 9th January 2015 (Friday) to: APSS SECRETARIAT G-1, Medical Academies of Malaysia, 210, Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia. TEL: (+603) 4023 4700, 4025 4700 FAX: (+603) 4023 8100 EMAIL: [email protected] * Any replies received after 9th January 2015 (Friday) will be subject to seats availability !