7Th Concise Course in Neuroanaesthesia

7th Concise Course in Neuroanaesthesia

15th November 2014

REGISTRATION FORM

Closing Date for Regular Registration: 1st November 2014

Early Bird Registration: on or before 30th September 2014

Name: ______

Department: ______

Hospital : ______

MCR No. for CME : ______

Handphone No. : ______

E-mail : ______

Course Fees (inclusive of course materials and lunch/tea breaks)

(Please tick √ one)

Medical Officers and Residents: $100 (early bird)□

$150 (regular rate)□

Specialists: $200 (early bird)□

$250 (regular rate) □

Payment Method

(Please tick √ one)

1. Cash □

2. Cheque □

Made payable to “TAN TOCK SENG HOSPITAL PTE LTD” with your name and

department on the reverse side.

3. Credit Card□

Please fill up additional credit card charge form

Please fax or send the completed form to:

Ms Nora Amin, Administrative Assistant,

Department of Anaesthesiology, Intensive Care and Pain Medicine

TanTockSengHospital

Tel: 63577772 Fax 63577772 E-mail:

/ Intensive Care Training
Address: Department of Anaesthesiology, Intensive Care and Pain Medicine, 11 Jalan Tan Tock Seng Hospital, Singapore 308433
Tel: 65-6357 7772 / Fax: 65-6357 7837 / Email:
SETTLEMENT OF COURSE FEES USING VISA/MASTERCARD
Please charge to my Visa/MasterCard account the following bills.

I) PARTICIPANT’S PARTICULARS

Full Name :
NRIC/Passport No. :
CoursesName / Amount / Course Date
7th Concise Course in Neuro-anaesthesia / $100 (Medical Officers/Residents – Early Bird)
$150 (Medical Officers/Residents – Regular Registration)
7th Concise Course in Neuro-anaesthesia / $200 (Specialists – Early Bird)
$250 (Specialists – Regular Registration)
II) CARDHOLDER’S PARTICULARS
Name as on the card :
Contact No.:
Visa/MasterCard No.: / / / / / /
CVV no. (found on the reverse side of the card)
Expiry Date :
M / M / Y / Y
Amount Charge: / S$
Cardholder’s Signature:

III) NOTICE TO PARTICIPANTS AND CARDHOLDERS

a) This form is only used by participants who wish to settle their course fees using their Visa/MasterCard. Participants who wish to settle their fees using other methods of payments are requested to ignore this form.
b) Please note that the above constitute an instruction given by the cardholder to Tan Tock Seng Hospital Pte Ltd to settle the course fees for the participant using the above Visa/MasterCard.
c) To avoid any form of inconvenience, all participants and cardholders are kindly requested to ensure the information furnished above are accurate and complete. This form must be returned to Tan Tock Seng Hospital Pte Ltd to the attention of the “Ms Nora Amin,Concise Course in Neuroanaesthesia, Department of Anaesthesiology, Intensive Care and Pain Medicine” on or before the due dates.
d) The hospital reserves the right to reject the use of a particular credit card.