Dr / Mr / Mrs / Ms (in BLOCK letters):

Institution:

Mailing Address:

Post Code: Facsimile:

Tel. Office: Tel. Mobile:

Email:

Yes No Attending the Congress Banquet (Saturday, 8th May 2010 at 7:30 pm)

Yes No Request for vegetarian food servings.

Select only one: Workshop 1 OR Workshop 2 Select only one: Symposium 1 OR Symposium 2 Select only one: Symposium 3 OR Symposium 4

REGISTRATION FEEDOCTORS RM250.00 This includes full admission to the congress, lunch,

congress banquet and tea breaks.

CME points will be accredited.NURSES/VOLUNTEERS RM200.00OTHERS RM200.00

Method of payment:I hereby enclose my payment of RM ___________ (cheque / postal order / money order/ government LPO) in favour of “PERAK PALLIATIVE CARE SOCIETY” being payment for my participation in the above congress.

Direct Bank-in Payment via bank deposit to Public Bank Bhd Acccount No: 3096888034 (please post / email / fax us a copy of the deposit slip).

Please send the completed form and payment by 30 March 2010 to:The Secretariat, 9th Malaysian Hospice Congress, 14 Lebuh Woods, Canning Garden, 31400 Ipoh, Perak.

FOR SECRETARIAT Use only:Date received Amount (RM) Receipt No

REGISTRATION FORM

9th MALAYSIAN HOSPICE CONGRESS

Impiana Casuarina Hotel, Ipoh, 7-9th May, 2010