REGISTRATION FORM
Please complete the form in capital letters and keep a copy for your records.
DELEGATE INFORMATION:
Title:
Prof
M.D.
R.N.
Mr.
Ms.
Last Name :
First Name :
Institution :
Department :
Mailing Address :
Country :
Telephone No. : (please include country code)
Fax No. : (please include country code)
Mobile No. : (please include country code)
E-mail address :
ACCOMPANYING PERSON INFORMATION:
Title :
Mr.
Ms.
Title :
Last Name :
Last Name :
First Name :
First Name :
Mr.
Ms.
REGISTRATION INFORMATION:
Please select the appropriate registration category:
Delegates :
Trainee w/ papers1 :
Trainee w/o papers :
Allied / Nurses :
Exhibitors :
VATS Workshop :
USD 500
USD 200
USD 400
USD 400
USD 300
USD 250
Regular
Registration
Between or on 01
September to 23
October 2015
USD 600
USD 200
USD 400
USD 500
USD 300
USD 250
Workshop All You Can2
USD 200
USD 200
Type of Registration
Accompanying Person :
Gala Dinner :
REGISTRATION TOTAL:



Early Bird
Registration
Before or on
31 August 2015
Late Registration
Before or on
On or After 24
October 2015
USD 700
USD 200
USD 400
USD 600
USD 300
USD 250
USD 200
USD 50
USD 50
Registration will be confirmed after receiving full payment. Those who do not receive a
confirmation notice before the congress are requested to contact the registration secretariat at
atcsa2015secretariat@atcsa.org. Only participants who complete their registration will be
included in the program.
The date of payment is decisive for the registration fee. Even if the registration form is received
before the early bird or regular deadline, it will not be considered as early or regular registration if
the payment has not been received before the deadlines.
The Association of Thoracic and Cardiovascular Surgeons of Asia plans to take photographs and
video material at the 25th Annual Congress of ATCSA in Mactan, Cebu and reproduce them in
ATCSA educational, news or promotional material, whether in print, electronic or other media,
including the ATCSA website. By participating at the 25th Annual Congress of ATCSA in
Mactan Cebu, you grant ATCSA the right to use your name, photograph and biography for such
purposes. All postings become the property of ATCSA. Postings may be displayed, distributed or
used by ATCSA for any purpose.
1
To be eligible for the trainee rates, they must submit and qualify for the paper presentation during the
Congress and written document signed by their respective Department Chairman or Training Officer that
they are still in training; otherwise regular fee for trainee will be applied.
2
Workshop all you can includes the following workshop EXCEPT VATS Workshop. This will be on a
FIRST COME, FIRST SERVED BASIS and LIMITED SLOTS ONLY.
 Cardiac Mitral Conclave Workshop
 ECMO Workshop
 Perfusion Simulation
 Cardiothoracic Anesthesia Workshop
DELEGATES FEE INCLUSION:




Delegates are entitled to access to all scientific sessions of ATCSA 2015.
Entrance to exhibition area.
Congress bag and other printed materials.
Coffee breaks to be served during the congress scientific program.
CANCELLATION POLICY – REGISTRATION:

Request for registration CANCELLATION must be received in writing by the ATCSA
2015 via email at atcsa2015secretariat@atcsa.org.
 Cancellations received before or on 31 August 2015 – eligible for 50% refund.
 Cancellations received on or after 01 September 2015 – NO REFUND.
Please note that registration refunds will be processed within 30 days after the end of ATCSA
2015 Congress, bank charges will be deducted from the refund.
PAYMENT INFORMATION:

Payment via Bank Transfer:
For payment via bank transfer please use the following bank account:
Account Name
Account Number
Bank Name
ATCSA 2015
0450-013931-530
Development Bank of the
Philippines
DBPHPHMMXXX
Swift Code



Bank charges are the sole responsibility of the participant and should paid in
addition to the fees.
All bank transfers should indicate the following information:
- Name of Sender
- Date of bank transfer
- Amount of bank transfer
Payment via Credit Card or Paypal:
Credit Card Number:
Cardholder’s Name:
Expiry Date:
Card Verification Code:
(Last 3 digits at the back of your card)
Date:
Cardholder’s Signature: