For Internal Use Only: APTHC 2012 Registration Form _________ 9th Asia Pacific Travel Health Conference 2012 (APTHC 2012) 2 – 5 May 2012 *Grand Copthorne Waterfront Hotel, Singapore REGISTRATION AND ACCOMMODATION FORM Please PRINT in BLOCK LETTERS and FAX, EMAIL or AIRMAIL to: Registration and Accommodation Dept. 10 Soi Lasalle 56, Sukhumvit Road Bangna, Bangkok 10260, Thailand Tel: +66 2 7487881, Fax: +66 2 7487880 E-mail : apthc2012@kenes.com Accompanying Person: Family Name First name Registration Fees EARLY BIRD Until 2 February 2012 in SGD $ REGULAR 3 February – 23 April 2012 in SGD $ ONSITE in SGD $ Doctor 630 730 750 Non-Doctor* 600 700 720 Day Registration 250 250 250 Accompanying Person*** 250 250 250 Category A** Countries 750 850 900 Category B** Countries 650 750 800 Day Registration 275 275 275 Accompanying Person*** 250 250 250 TYPE Member, APTHS & ISTM Non-Members of APTHS & ISTM *Non-doctors refer to nurses, pharmacists, allied health professionals, interns, and students who do not have M.D or PhD degrees **Country classifications with reference to WHO geographical indicators ***Fee includes a one-day city tour, entrance to exhbition, Opening Ceremony and Welcome Reception ****prevailing Government Taxes is applicable to ALL LOCAL delegates Page 1 of 2 APTHC 2012 Participant’s name _______________________________________ How did you learn about this congress? (Please choose one) Colleague / Co-worker Congress Brochure E-mail Newsletter Sponsor Search Engine (i.e. Google) Society/Professional Websites Online/Print Journal Internet event calendars Online Discussion Groups Other Please indicate type of facility where employed (choose one) Hospital University University Hospital Private practice Research institute Laboratory Industry Press Comprehensive Care Clinic Government agency Other (please specify) ___________________ Please indicate your professional role (choose one) Clinical practitioner Clinician researcher Basic science researcher Epidemiology/Statistics Nurse/Healthcare practitioner Health administrator Industry/Corporate professional Student Resident Other (please specify) ____________ Please indicate your specialty field (choose one) Internal Medicine Immunology Public Health Occupational Therapy Microbiology/Virology Other - please specify ________________ Please indicate your clinical interests (choose up to two) Antibiotics Dermatological aspects Emergency Medicine HIV Immunopharmacology Immunosuppression Immunotherapy Infectious Diseases Paediatric Aspects Preventive Medicine Travel Medicine Tropical Medicine Vaccines Viral Hepatitis Other - please specify ______________________ Please indicate your dietary preferences (choose one) No preference Vegetarian Halal Others – please specify ____________________________________ Accommodation Official Hotel for APTHC 2012 will be at the Grand Copthorne Waterfront Hotel, Singapore. Please indicate your preferences below and we shall revert back to you with further details and information on room booking/reservations, by email: Room Type Price Range (rate per room per night inclusive of breakfast) Single Double Twin-share Single SGD $ 270++ Double, Twin SGD $280++ Smoking Non-smoking Travel Details Check in Check out Total night/s * I will share my accommodation with: Payment Please indicate the amount enclosed and preferred mode of payment. Ensure that you send your fully completed registration and accommodation form together with your payment: Registration Fee: SGD $ __________ Accommodation: SGD $ __________ Total: SGD $ _______ Option 1: Credit Card Visa MasterCard Number Expiry Date (month/year) Verification No. Name as shown on card: Family Name First name Signature Date (day/month/year) Passport number Option 2: Bank Transfer - with your name and address indicated on the reverse. If payment is made for more than one person or by a company, please make sure all names are indicated and send fully completed registration and accommodation forms together with a copy of the bank transfer. Please remit in Singapore Dollars only to the following account: Account Name: Kenes MP Asia Pte Ltd Account number: 003-915751-7 Bank Name: DBS Bank Ltd., Singapore Bank Address: 6 Shenton Way, DBS Bldg Tower 1, Singapore 068809 Swift Address: DBSSSGSG *Bank charges are the responsibility of the participant and should be paid at source in addition to the registration and accommodation fees. *Please make sure the name of the conference and the participant are stated on the bank transfer. CANCELLATION POLICY – Registration Faxed, emailed or post-marked: Notification received before 2 January 2012– 100% refund (minus SGD30 handling fee). Notification received from 2 January to 2 April 2012 – 50% refund. No refund on cancellations received after 2 April 2012. CANCELLATION POLICY – Hotel Accommodation Any cancellation upon confirmation of booking will be subject to one-night penalty charge. No-show on actual check-in day will be subject to one-night penalty charge. Credit card details are required for hotel reservation confirmation. Date Signature By signing this form you authorize Kenes Asia to charge the above credit card for the balance of your account two weeks prior to your arrival for services rendered. Page 2 of 2