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APPLICATION FORM

REGISTRATION FORM


The First Annual Neuro ICU Symposium


"Cutting-edge Management of Neurological and Neurosurgical Emergencies and Critical Care"
January 16th - 19th, 2019


 



BIODATA

Title          
Other Title
Name
* This name will be printed on the certificate
Date of Birth(dd/mm/yy)
City of Birth
Position/Designation
Institution/Organisation/Hospital/Afiliation
Mailing Address
Telephone
Mobile
Email
Web
Sponsored By
Company
Contact Name
Phone
I would like to register as
Title of the Presentation
I need accommodation

REGISTRATION SYMPOSIUM FEE

IDR. 2,500,000
IDR. 2,000,000
IDR. 2,000,000
-


REGISTRATION WORKSHOP FEE

IDR. 3,000,000
IDR. 1,000,000
IDR. 3,000,000
-

* if the minimum number of participants did not meet the quota, the workshop will be rescheduled or the committee will refund the payment



ACCOMMODATION FEE

Hotel Name Room Type Price Check In Check Out Room

PAYMENT THROUGH :
* (Please Fax us the copy of bank advice after the bank transfer)









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