2018 KUALA LUMPUR NICOTINE ADDICTION INTERNATIONAL CONFERENCE

9th to 11th JULY 2018

REGISTRATION FORM

SECTION 1

Personal Information(* required)

Title: Prof / Dr / Datuk / Datin / Mr / Mdm / Ms

*First name

*Last name

*Profession

Professional (Malaysian) / Professional (International)
Student (Malaysian) / Student (International)

*Gender

Male / Female

*IC/Passport No

*Organization

*Personal Email Address

Telephone No

Mobile No

Fax No

Primary address

*Personal Address

*City

*Country

*Postal Code

Organization/Company Sponsor Information (If any)

*Contact person’s Name

*Institution/Company Name

*Telephone No

*Fax No

*Email Address

* I hereby declare

I am not affiliated to any tobacco/vape related companies or manufacturers.

The details that you enter above will be used by the Conference Secretariat for conference purposes only, including conference documentation such as ID badges, Letters of invitation and Certificates of attendance.

SECTION 2

Dietary requirements

Please select (/) your meal preference to helps us better prepare menus for KLNAC 2018.

Non-Vegetarian
Vegetarian

SECTION 3

Registration Fees

Pre-Conference (KLNAC2018 Workshop)

Registration Category / Rate
(Up to 30th April 2018)
Local Practitioner / General / MYR 200
International / USD 150

Please select (/) your preferred session.

Pre-SCOPE Training (Allied Health Provider)
SCOPE Training (Health Provider)
Advocacy
Motivational Interviewing
Quitline Training
International Tobacco Control Network (ITC) Statistical Workshop

Poster Presentation

Please select (/) your theme.

Treatment
Policy
Advocacy
Innovation

Conference

RegistrationCategory / Rate
Up to
30th April 2018 / After
30th April 2018 / Walk-In
Onsite
Professional (Malaysian) / MYR 650 / MYR 750 / MYR 850
Professional (International) / USD 650 / USD 750 / USD 850
Student (Malaysian) / MYR 390 / MYR 450 / MYR 550
Student (International) / USD 390 / USD 450 / USD 550

*All prices quoted are subject to 6% Good & Services Tax (GST).

* The USD rates are subject to change based on prevailing exchange rates.

SECTION 4

  1. Top of Form

Bottom of Form

Top of Form

Cancellation Policy

The policy regarding cancellation of paid registrations is as follows:

By30th April2018 / 80% refund
After 1stMay 2018 / No refund will be made

Cancellations must be notified in writing (e-mail or submission of the cancellation form through the registration system is sufficient) to the Conference Secretariat. The amount to be refunded will be calculated according to the date when the cancellation notice is received. All refunds will be paid after the conference.

SECTION 5

Payment method

Bank-In / Wire Transfer
Cheque
Limited Purchase Orders (LPO)
Postal Order

Payment details

Kindly issue payment in favour of

Account Name: Bendahari Universiti Malaya

Bank: CIMB Bank (Universiti Malaya)

Account No: 8001279998

Reference: KLNAC2018(Please state as your payment reference)

CONTACT US

KLNAC2018 Secretariat

Registration

1. Dr Effariza Hanafi

2. Ridza Azizi

Email: