PHILIPPINE COLLEGE OF CHEST PHYSICIANS
33rd Annual Chest Convention
March 5-8, 2014  SMX Convention Center, 3/F SM Aura Premier Taguig
Theme: PULMONARY L.I.N.K.S. (Leadership In New Knowledge & Skills)
REGISTRATION FORM
DELEGATE
Surname:
Mailing Address:
Please Type or Print
MI:
Given Name:
PRC #
Fax/E-mail Address:
Telephone:
Mobile #
CATEGORY:
 PCCP Member
 Non-member Delegate
 Government Physician
 Resident
 Intern
 Respiratory Therapist  Medical Technologist
 Fellow-in-Training
 Nurse
REGISTRATION FEES
 Check if you are disabled and require
assistance (attach a written description of needs)
Registration will be processed only when
accompanied by total payment. Reproduce forms for
additional registration. Entire form must be submitted.
I will attend:
CONVENTION PROPER (March 6-8, 2014)
PRE-REGISTRATION
(on or before Jan. 31, 2014)
ON-SITE
 Member
1,300.00
1,600.00
 Non-Member
1,500.00
1,700.00
 Government Physician
1,400.00
1,600.00
 Fellow-in-Training / Resident / Intern /
Paramedical
1,100.00
1,300.00
$ 100
$ 100
CATEGORY
 Foreign Delegates
PAYMENT PROCEDURE
Check payment should be made payable to PHILIPPINE COLLEGE OF CHEST PHYSICIANS
Return this form and payment to 33rd ANNUAL CHEST CONVENTION
Philippine College of Chest Physicians Convention Secretariat
You can also deposit the payment at Bank Name: Bank of the Philippine Island (BPI)
Acct. Name: PHILIPPINE COLLEGE OF CHEST PHYSICIANS
Current Account # 1991-0065-12
 Kindly fax this form together with the deposit slip @ 924-0144 or e-mail at andrea.santiago@philchest.org
For inquiries contact: PCCP Secretariat - Telephone Number: (632) 924-9204; Telefax Number: (632) 924-0144
E-mail Address
: secretariat@philchest.org and andrea.santiago@philchest.org