Chest Tube Insertion Course
Closing Date: 9 April 2010
Registration Form
Salutation
(pls delete as applicable)
Prof / A/Prof / Dr / Mr / Mrs / Ms
Name
(to be printed on
Certificate)
Institution / Department
Address
Office Contact
Mobile Contact
Designation
MCR Number
Email Address
(confirmation will be sent
via email)
Registration Fee
NHG / NUHS Staff


S$ 261
Others
S$ 290
Payment by Cheque


Bank / Cheque Number: ________________________
Please make cheque payable to “National University Hospital (S) Pte Ltd” and
on the reverse side, please state “Chest Tube Insertion Course”
Send cheque to “5 Lower Kent Ridge Road, Service Block, Level 1, Singapore
119074” and attention it to “Ms Yvonne Lin”.
Payment by Credit Card
 Visa

 Mastercard
 American Express
Card Number (16 digits)
Expiry Date (mm/yy)
Cardholder’s Name (as on card)
Signature
Payment through Cost Centre (NHG / NUHS staff only)
Cost Centre Number
Dept Secretary’s Name
Dept Secretary’s Contact Number
Cancellation Clause
Any cancellation or replacement must be conveyed to Ms Yvonne Lin (yvonne_lin@nuhs.edu.sg)
by email. A cancellation charge of 50% of fess will be levied if the cancellation is received before
09 April 2010. There will be no refund of fee if the cancellation is made on or after 9 April 2010.
15 March 2010