International Symposium on Cardiovascular and Neurovascular

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Live 3D TTE/TEE Practical Training Course
23-24 November 2012 (Fri-Sat)
Seminar Room 2 (Room 303),
Li Ka Shing Medical Sciences Building,
Prince of Wales Hospital
(Unrestricted Educational Support for This Program Courtesy of Philips Healthcare)
REGISTRATION FORM
*Please complete ONE form for each delegate. Please “” where appropriate.
Secretarial use only
Reg. No:
Date:
*Please send the completed registration form together with payment details to the
Congress Secretariat by fax, email or mail.
Personal Information
Title:
Prof.
Dr.
Mr.
Ms.
Gender:
First Name:
Male
Female
Last Name:
Position:
Department:
Institution:
Address:
Country:
Tel.:
Email:
(
)
Fax:
(
)
Registration Details
Category
Registration Fee
Physician
Quantity
Amount
HKD10,000 / USD1,300
Please issue an invitation letter for application of travel visa
Total:
Payment Method
Please debit my credit card:
Visa
Master
Credit Card No:
Expiry Date:
Name of Cardholder:
Amount:
A cheque for HKD
HKD/USD
made payable to “The Chinese University of Hong Kong” is enclosed.
A bank draft for HKD/USD
made payable to “The Chinese University of Hong Kong” is enclosed.
*Payment by cheque / bank draft should reach the Congress Secretariat within 2 weeks after submitting the
registration form
Signature:
Organized by:
Date:
Congress Secretariat:
Division of Cardiology, Department of Medicine & Therapeutics, The Chinese
University of Hong Kong, 9/F., Clinical Sciences Building, Prince of Wales
Hospital, Shatin, N.T., Hong Kong
Tel.: (852) 2647-6639
Fax: (852) 2144-5343
Email: [email protected]
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