ASIA PACIFIC PHARMACEUTICAL SYMPOSIUM 2009 (APPS 2009)

ALA CARTE SYMPOSIUM REGISTRATION FORM (MALAYSIANS ONLY)

( * ) Please fill in the mandatory field

(A) PERSONAL DETAILS

First Name*

Middle Name (optional)

Last Name*

Name on APPS Name Tag(maximum 12 characters)*

Gender*

Male Female

Date of birth*

(dd/mm/yyyy) 

Identity card number
(for Malaysian delegates)
Passport number
(for International delegates) *

Religion

Nationality*

 

Name of University/College/Institute*

Graduation Year

Spoken Language(s)

T-shirt size*

S   M   L   XL   XXL  

Size

Chest Width (inch)

S

38

M

40

L

42

XL

44

XXL

46

 

(B) PARCITIPANT'S CONTACT DETAILS

Postal address

(Address Line 1)*

(Address Line 2)

(City)

(Province/State)

(Postal Code)

(Country)*

 

E-mail address*

Contact Number

(Home)

(Mobile)*

(C) FOOD AND HEALTH INFORMATION

1. Are you allergic to any food? *

Yes No

If yes, please specify:

2. Do you have any allergies to any medication? *

Yes No

If yes, please specify:

3. Are you a vegetarian? *

Yes No

If yes, please specify:

4. Do you have any medical conditions that require special attention? *

Yes No

If yes, please specify:

(D) SPECIAL ACCOMMODATIONS

If you require any special accommodations (i.e. sign language interpreter, wheelchair access, etc.), please specify:


(E) EMERGENCY CONTACT

In the case of an emergency, we should contact

Full name*

Relationship*

Country*

 

Email address*

Contact number

(Home)

 

(Mobile)*

(F) MEMBERSHIP INFORMATION

Are you a member of MyPSA or MPS? *

Yes No


Which of the following best describes your involvement/role at the APPS? *

Local Pharmacy Student
Pharmacist

Others:

(G) POST-SYMPOSIUM TOUR

1st July 2009 - 3rd July 2009

Registration fee

USD 200

Would you like to join Post-Symposium Tour? *

Yes No

(H) LEADERS IN TRAINING(LIT) PROGRAM

23rd June 2009 (starts from 5.00pm) - 26th June 2009 (ends at 5.00pm)

Registration fee

120 USD

Would you like to join the Leaders in Training (LIT) Program ? *

Yes No

(I) DISCLAIMER

I , with NRIC or passport No. , hereby declare that I will not hold the Secretariat of Asia Pacific Pharmaceutical Symposium 2009 responsible for an event of a mishap or an accident. 

 

Date:

 

Note: Please attach and send your passport size photo to apps09usm@gmail.com (size not more than 1MB, format: jpeg)*

 

 

For further information regarding registration, please refer to the registration guideline.