abbas’s advanced course in basic and clinical immunology...
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Abbas’s Advanced Course in Basic and Clinical Immunology Organized by Allergy, Asthma and Immunology Association of Thailand (AAIAT) November 6-8, 2014 Bangkok, Thailand.
*** REGISTRATION FORM ***
(Please write your name in capital letters clearly as it will be printed on your certificate)
Title Dr./Prof./Mr./Mrs/Other (specify………..)................................................................…………………………......................................................
Family Name Middle Name First Name
Institution/Affiliation .............................................................................…………………………................................................................................
Correspondence Address......................................................................................................………………………….....................................................
City……................................................State............................................................Zip Code............................ Country................................................
Telephone (Office)......................................Telephone (Resident).................................Mobile........................................Email…………….................
Gender: Male Female
Meal Preference: Vegetarian Non-Vegetarian
Registration Category and Rate (Please tick as applicable)
Registration Category (Please tick as applicable) Abbas’s Advance Course
Participant Early Bird Registration
(before July 30, 2014)
Regular Registration
(before September 30, 2014)
One Day Registration
(before September 30, 2014)
Oversea Participants USD 200 USD 250 USD 150
Thai AAIAT
Members/Fellows
THB 3,500 HB 4,000 THB 2,500
Thai non-AAIAT
Members
THB 4,500 THB 5,000 THB 3,000
Thai Students THB 2,500 THB 3,000 THB 2,000
Entitlements
÷ Lunch and two tea/coffee breaks each day
÷ Handouts, scientific program, name badge, certificate of attendance
For students :
Together with registration form, a student must submit
a valid student ID or certificate copy and importantly the
endorsement of supervisor or head department.
I certify that .............................................................. is the current
student of our program/department.
......................................................................................
(Supervisor or Head of the Department)
(Date) ………………………………………
Abbas’s Advanced Course in Basic and Clinical Immunology Organized by Allergy, Asthma and Immunology Association of Thailand (AAIAT) November 6-8, 2014 Bangkok, Thailand.
Mode of Payment
Bank Transfer Only:
Account / Beneficiary Name: Abbas’s Advance Course
Account Number. : 405-1-04778-2
Bank Name: Siam Commercial Bank Public Company Limited (ธนาคารไทยพาณิชย)
Branch: King Chulalongkorn Memorial Hospital Branch (สาขาโรงพยาบาลจุฬาลงกรณ (อาคาร ภ.ป.ร.))
Swift Code: SICOTHBK
Address : 1873 RAMA IV Road, Pathumwan Sub District, Pathum Wan District, Bangkok 10330
Send form via e-mail: [email protected]
Swift Code & Accounts details as below:
Payments In USD: EEFC account (USD) # 52005007875 (Swift Code – SCBLINBBXXX)
Important notes:
*Download the registration form & send the duly filled form to the Course secretariat along with the bank remittance
copy.
*The registration fees should reach in our bank account within seven working days of submitting the form or else your
registration will be deemed cancelled.
*The registration fee does not include the bank charges.
*All bank charges / fees are to be borne by the delegate.
*If we receive the registration fees after deducting the bank charges, we shall inform you of the same and registration will only be
completed after the full payment is made.
*Please e-mail the copy of bank transfer remittance after making payments to [email protected] for records of the
secretariat.
*Registration Confirmation letter along with your registration ID will be emailed to you within 15 days as soon as payments are
received in the association account.
Cancellation Policy.
÷ No refund will be made for any cancellation.
MAIL:
Send Registration Form to:
Mrs. Siriporn Timprasert
The Allergy, Asthma and Immunology Association of Thailand (AAIAT)
E-mail : [email protected]
Mobile: 092-865-5338 (dial +66 from overseas)
