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
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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.
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