| Salutation |
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| First Name * |
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Last Name * |
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| Organisation/Hospital |
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| Department |
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| Address |
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| Country |
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| Zip Code |
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MCR No
(for local delegate) |
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| Tel |
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Fax |
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| Email Address * |
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Category |
Early Registration
on & before
31 August 2009 |
Standard Registration
on & after
1 September 2009 |
On Site Registration |
| Delegate (Member) † |
S$700 |
S$750 |
S$800 |
| Delegate (Non Member) |
S$750 |
S$800 |
S$850 |
| Accompanying Person |
S$250 |
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| † Members |
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| ISSM |
International Society for Sexual Medicine |
| APSSM |
Asia Pacific Society for Sexual Medicine |
| AGSSM |
Africa Gulf Society for Sexual Medicine |
| ESSM |
European Society for Sexual Medicine |
| SMSNA |
Sexual Medicine Society for North America |
| SLAMS |
Sociedad Latinoamericana de Medicina Sexual |
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Yes, I shall be attending. |
Dietary Requirement
Vegetarian |
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| Accompanying Person registration fee will include one Accompanying Person's Tour, one Conference Welcome Reception and one Conference banquet. The Accompaying Person MUST travel with a delegate attending the Conference. |
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| First Name |
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Last Name |
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| Description |
Amount per person |
No. of Tickets |
Welcome Reception
(Saturday, 12 December 2009) |
$$40 |
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Conference Banquet
(Monday, 14 December 2009) |
S$120 |
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| I wish to submit
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| Payment Mode |
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| If paying via credit card: |
| Card Type: |
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Cardholder's Name |
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| Card Number: |
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CVV Code: |
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| Card Expiry Date |
/
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I am paying via telegraphic transfer / bankdraft |
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Please quote the following bank account:
Account Name: APSSM2009
Bank Account Number: 591-291299-001
Swift Code: OCBCSGSG
Name of Bank:
Overseas Chinese Banking Corporation Limited
65 Chulia Street
Singapore 049513 |
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| If paying by cheque |
| Local cheque is made payable to "APSSM2009" |
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| Note |
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- All bank charges for payment via Telegraphic Transfer or Bankdraft is borne by the delegate. In the event there is a shortfall of payment recieved for either your registration fee payment or hotel payment, the secretariat will collect the balance payment.
- Orient Explorer (S) Pte Ltd acts on behalf of the 12th Biennial Meeting of the Asia Pacific Society of Sexual Medicine to handle all fee collection. All credit card charges will be made by the merchant name: Orient Explorer (S) Pte Ltd.
- Cancellation and refund policy will apply accordingly.
- Full payment must be remitted. Registrant should borne all transactional bank charges at source. The Secretariat will advise on any shortfall with remittance and follow up with the recoupment requirement. Topping up costs more. Please make correct payment.
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