Organized by:
Co-Organizers:
CENTRE APP ASIA PTE LTD (CAPP Asia) is an ADA CERP Recognized Provider. ADA CERP is a service of the
American Dental Association to assist dental professionals in identifying quality providers of continuing dental
education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply
acceptance of credit hours by boards of dentistry.
REGISTRATION FORM
––
Mr/ Mrs/ Ms/ Dr:
CAPP Designates this activity for 14 CE Credits
CRN NO:
201213499H
DCR#(Singapore Participants Only):
Last Name:
Given Name:
Specialty:
Clinic:
Country:
City:
P.O. Box:
Tel:
Fax:
Mobile:
Email:
Category
Early Bird
(Valid until August 31st)
After August 31st
After November 31st
On Site
Dentists
400 S$
450 S$
480 S$
520 S$
SDA Members
350 S$
400 S$
430 S$
470 S$
Dental
Auxiliaries
300 S$
330 S$
350 S$
420 S$
Dental
Students*
270 S$
290 S$
320 S$
390 S$
340 S$ - min 3 pers
390 S$ - min 3 pers
420 S$ - min 3 pers
Not Available
Group
* Applicable for full time students only. Normal rates apply otherwise. Proof of student identity required onsite before badge
collection.
I want to receive news and updates by email
METHOD OF PAYMENT
●Credit Card
Visa
MasterCard
Card Number: ……………………………………………………………
Card Holder’s Name: …………………………………………
Expiry Date: ……………………………………
Card Security Code: ……………………….
(last 3 digits on the back of the card)
Billing Address: ……………………………………….......................................................................................................
Country: ………………………………
Date: ……………………….
●Bank Transfer
Account Name: Centre APP Asia Pte Ltd Account #: 588-120477-001
Bank Name: OCBC BANK
OCBC Bank Code: 7339
Bank Address: 65 Chulia Street OCBC Centre Singapore 049513
Branch Code: 588
Swift Code: OCBCSGSG
● Cheque payable to: Centre APP Asia Pte Ltd
Branch Code: 517
Swift Code: OCBCSGSG
Signature: ………………………………………
AUTHORIZATION NOTE
*3 % Charges for CC Payment
Please debit my credit card with an amount of S $
(in digits) ......................................................................................
(in letters) ....................................................................................
for the 3RD Asia Pacific CAD/CAM & Digital Dentistry
International Conference. The card holder will honor this
transaction and not hold CAPP responsible if the credit card
number has been compromised. REFUND POLICY: A Refund of the
registration fee will be made as follows: Notification in writing by 01
November 2015 -50%refund. After 1 November 2015 – no refund can be
given.
Please fill in the form and email / fax / mail back to:
CENTRE APP ASIA Pte Ltd
Address: 13 Kaki Bukit Road 1, #03 - 03 Eunos Techno Link Singapore 415928