Dermatological Society of Malaysia

34th Annual Dermatology Congress & AGM
10-13 December 2009 The Andaman, Langkawi, Kedah
Theme: “Cutting Edge" Dermatology

Registration Form
*Indicate fields that are required.

*Title :
*Name :
*Address :
*Postcode :
*Country :
*Office Telephone :
Fax :
Mobile :
E-mail :
Membership :



Accompanying person Age Relation to Delegate
1.    
2.    
3.    
4.    
 

If you wish to bring more than 4 accompanying persons, kindly list their details here:

*REGISTRATION FEES

 

 After 30th October 2009   No. Attending Total
PDM Ordinary member RM 700   
PDM Associate Member RM 750  
Non PDM member RM 800  
Allied Health Staff RM 600  
Accompanying person
(adult)

 RM 500  
Accompanying person
(1/2 price for child
4 - 12 years old)

RM 360  

PRE-REGISTRATION WORKSHOP

DAY REGISTRATION Associate member RM 400
  Non PDM member RM 450

ANNUAL DINNER
12 December 2009

Langkawi Tour
11 December 2009

 RM 100 (for Assoc & Non-members)
(please book early, limited seats only)

PRE-CONGRESS WORKSHOP :
Dermatologic Surgery (10th Dec 09)
(Open to dermatologists and postgraduate trainees ONLY. No fee; registration required)

  
    GRAND TOTAL:

PAYMENT METHOD

Cheque    
Please send cheque No. for RM issued in favour of  "PERSATUAN DERMATOLOGI MALAYSIA" with completed form to PDM Conference Secretariat address below:
Telex Transfer / Bank Draft    
Please remit RM to:
Bank : Public Bank Berhad
Address : Raja Chulan Branch, Wisma Lim Foo Yong
86 Jalan Raja Chulan, 50200 Kuala Lumpur, Malaysia
Account Name : Persatuan Dermatologi Malaysia  
Account No. : 3077 451626 01
Swift No. : PPBEMYKL

Please fax bank statement as proof of payment to the Secretariat at +603 7880 3170 and bring along original transaction slip to the conference.

PDM Conference Secretariat:
c/o Dr Mardziah Alias
Suite G-07, Ground Floor Damansara Specialist Hospital,, 119, Jalan SS20/10 Damansara Utama 47400 Petaling Jaya.
Tel: 03-7722 2692
Fax: 03-7722 2617

Contact person
:
Ms Wong Chooi Leng
Telephone : +603 7880 8710 ext 16
Fax : +603 7880 3170
Online registration : www.dermatology.org.my
Email : chooiling.wong@leo-malaysia.com

For Hotel Reservation,
Please contact Ms Marhani bt Omar
Tel: +603 2163 5112
Fax: +603 2163 5116
H/phone: +6016 288 3339
Email: marhani.omar@ghmhotels.com.my

Refunds policy: No refunds for cancellations after 30 October 2009. Refunds of 50% only with written notice of cancellation before this date.