PARTICIPANT DETAILS:(Please type or write your particulars in BLOCK letters and tick as ‘√’ where appropriate)

REGISTRATION FORM

Full Name: Organisation: Title: Mr. Ms. Mrs. Miss Prof. Dr. other:_______________________Affiliated Organisation/ Institution:

Address: Postcode:______________ Country:___________________

Contact Number : Office Mobile FaxE-mail:MAPS Membership: Yes, Membership Number:________________________ No membership

Participant Type:I wish to attend the conference as a participantI wish to make a presentationI am an Exhibitor

Presentation Oral Poster (Size: A1)

Presentation Title:

Early Registration Fee(before 30th June 2017)

Standard Registration Fee (after 30th June 2017)

Registration Fee:

Student (member) MYR 500 MYR 600Registered MAPS Member MYR 750 MYR 850Non-member MYR 950 MYR 1050International Student USD 200 USD 250International Delegate USD 300 USD 350

Meal Choice Non-Vegetarian VegetarianConference Dinner Yes No

Mode of payment:

CashBank draft/ Cheque (for Malaysian only)Bank Draft Number/Cheque Number:____________________Issuing Bank:________________________ Date of Transaction:____________________Bank transfer (for Malaysian only)Transfer Receipt Reference Number:_____________________Issuing Bank:________________________ Date of Transaction:____________________Bank Cheque (for Malaysian only)Cheque Number:____________________Issuing Bank:________________________ Date of Transaction:____________________Local Order (for Malaysian only) LO reference No.:_____________________________Telegraphic Transfer*:(T.T. Reference No.:____________________ T.T. Bank: __________________________Date of Transaction:____________________ )