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REGISTRATION FORM Please complete and send this form by fax (Fax: +603 2161 6560) or email [email protected] PLEASE TYPE or WRITE CLEARLY IN BLOCK LETTERS A. Contact Person’s Details Name (Prof/Dr/Ir/Mr/Mrs/Ms)............................................................................................................................................ Company Name…………………………………………………………………………………………………………………………………………………………….. Designation…………………………………………………………………………………………………………………………………………………………………….. Address …………………………………………………………………………………………………………………………………………………………………………. Postcode:…………………………………………………………………………………. Country:……………………………………………………………………… Tel:...................................................... Mobile:………………………………………………Facsimile: …………………………………………………… Email:……………………………………………………………………………………………………………………………………………………………………………… C. Participant’s Information 1. Name Prof/Dr/Ir/Mr/Mrs/Ms)……………………………………………………………………………………………………………………………………………………. NRIC/Passport No……………………………………………………………………… Designation…………………………………………………………………. Mobile……………………………………………………………… Email…………………………………………………………………………………. Networking Dinner ☐ Dietary Preference: ☐Vegetarian 2. Name Prof/Dr/Ir/Mr/Mrs/Ms)………………………………………………………………………………………………………………………………………………….. NRIC/Passport No……………………………………………………………………… Designation………………………………………………………………… Mobile……………………………………………………………… Email………………………………………………………………………………… Networking Dinner ☐ Dietary Preference: ☐Vegetarian 3. Name Prof/Dr/Ir/Mr/Mrs/Ms)……………………………………………………………………………………………………………………………………… NRIC/Passport No……………………………………………………………………… Designation…………………………………………………………………. Mobile……………………………………………………………… Networking Dinner ☐ Dietary Preference: ☐Vegetarian Email…………………………………………………………………………………. 4. Name Prof/Dr/Ir/Mr/Mrs/Ms)…………………………………………………………………………………………………………………………………………………… NRIC/Passport No……………………………………………………………………… Designation…………………………………………………………………. Mobile……………………………………………………………… Email…………………………………………………………………………………. Networking Dinner ☐ Dietary Preference: ☐Vegetarian D. Registration Fees Early Bird Registration Normal Price Registration Fees Before 31st Jan 2015 31st Jan 2015 onward Public Fee ☐ MYR 3000 / USD 1000 ☐ MYR 3,400 / USD 1133 Group Fee for 4 or more bookings ☐ MYR 2400 / USD 800 ☐MYR 2,800 / USD 933 Student ☐ MYR 500 / USD 167 ☐ MYR 500 / 167 Networking Dinner ☐ MYR 30 / USD 10 ☐ MYR 30 / USD 10 * Registration Fees include conference sessions, refreshments, luncheons, but not the optional technical tours, dinner, airport transfer and accommodation. * The RM/USD conversion rate is FIXED at RM3.00 = USD1.00 for the conference and is not subject to any current rate that may differ * Please fill up the membership ID in order to entitle for special rate. * Any payment made after 1st April 2015 will be subject to GST. * Acceptance of Registration is at the sole discretion of the Organising Committee. Confirmation of Registration will be sent in writing upon receipt of full payment. Government & Partner Discounts Government and partners participating in PIECE 2015 are entitled to 25% discount off the INDIVIDUAL Fee and a further 10% of the Group Fee ☐ Government Discount Member of organisation: ________________________ Membership Number:………………………………………………….. Registration Fees (per pax) ………………………Number of registered (pax): …………………Grand Total:……………………………… F. Payment Details Enclosed is my total payment of USD / MYR………………………………………………. to be made through: (tick appropriate box) ☐ 1. Telegraphic Transfer T.T Reference No:………………………………………………….. T.T From (Bank Name):………………………………………………… *Important Note: Please scan your TT slip and email to the conference secretariat for verification. ☐ 2. Company Cheque Cheque No:…………………………………………………………………………………………………………………………………………………… Cheque Issuing Bank:……………………………………………………………………………………………………………………………………. *Important Note: Kindly make the payment to Persatuan Syarikat-Syarikat Konsesi Lebuhraya Malaysia ☐ 3. Local Order (Reference No) …………………………………………………………………………………………………………………… 4. Credit Card: ☐ Visa ☐ Master ☐ Amex I authorise MCI Management Malaysia Sdn Bhd to debit the total amount of USD / MYR…………………….from my credit card (details provided below)for the registration fees. ☐ Name of Card Holder:…………………..……………………………. Credit Card Number:…………………………………………………………….. Expire Date (MM/YY)………………………………………………… Card Issued by (Bank)…………………………………………………………………… *CBC/CVC Code………………………………………………………. *Visa/Master: The last 3 digit number on the reverse side of your card. *AMEX: The 4 digit number on the left/right of your card. Card Holder’s Signature:………………………………………………………………………………………………… Date:…………………………………… G. Term and Conditions: Delegates can make payment by Telegraphic Transfer, Company Cheque, Local Order or Credit Card. - Please note that all related bank charges, financial charges or credit card commission (5%) are to be borne by the delegates and are not to be deducted from the fees payable to the conference. - Official receipt will be provided only upon request. Substitution of Delegate(s) - This is allowed, provided the conference secretariat is notified in writing of the name and the designation of the new delegates(s) any time prior to the commencement of the event. Transfer of registration to other programmes is not allowed. Confirmation - Registration will only be confirmed upon receipt of FULL PAYMENT. - Upon receipt of the FULL payment, the conference secretariat will send you a confirmation letter via email. - Please bring along the confirmation letter and present it upon registration at the Conference. Cancellation Policy All cancellations of registration must be in writing to the conference secretariat. Refund will only be made AFTER the Conference. If cancellation is received - On or before 25th April 2015 a full refund (minus an administration charge of 10% of the registration fees ) After 25th April 2015 to 15th May 2015 50% refund (minus an administration 10% of the registration fees given ) After 15th May 2015 no refund will be given but a substitute delegate is welcomed to take your place or a set of documentation will be given. *paid registration fee is not refundable after the stipulated date for whatever reasons, including failure of obtaining VISA. Payment Details - Telegraphic Transfer or Company Cheque or Local Order are to be made to the following Conference bank account: Account: Account No: Bank Name: Swift Code: Persatuan Syarikat-Syarikat Konsesi Lebuhraya Malaysia 8602149181 CIMB Bank CIBBMYKL CONTACT DETAILS PIECE 2015 Conference Secretariat MCI Management Malaysia Sdn Bhd Suite 12.9, Level 12, Wisma UOA 2, Jalan Pinang 50450 Kuala Lumpur. Tel: +603 2162 0566 Fax: +603 2161 6560 Email: [email protected]
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