ASIA PACIFIC PHARMACEUTICAL SYMPOSIUM 2009 (APPS 2009)

GROUP REGISTRATION FORM

( * ) Please fill in the mandatory field

(A) PERSONAL DETAILS

First Name*

Middle Name (optional)

Last Name*

Contact Person*

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) ACCOMMODATIONS

if you have a preferred roommate for a twin-sharing room, please fill in his/her details below.


if you do not have a preferred roommate, please leave this section blank.

    Name :


   Country :  


   IC/Passport number:

 

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 IPSF? *

Yes No

If yes, please specify:


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

International Pharmacy Student
Local Pharmacy Student

Indvidual Member of IPSF
Official Delegate, if so, which organization?
IPSF Executive Member
IPSF Regional Officer
APRO Subcommittee Member

APRO Alumni (i.e. People who had held past office positions in APRO)

IPSF Alumni (i.e. People who had held past office positions in IPSF)
Pharmacist

(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.