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REGISTRATION FORM
PARTICIPANT
Name
City/Country
Hospital / Company
Phone
SPONSOR
Company
Contact Person
Phone
PRE-SYMPOSIUM Workshop & Course.
The Stones Hotel (July 30 - 31, 2019)
The Stones Hotel (July 31, 2019)
SYMPOSIUM
Specialist & Professional
GP / Nurse / Resident / Student
POST SYMPOSIUM Workshop & Course
The Stones Hotel (August 3, 2019)
The Stones Hotel (August 3 - 4, 2019)
ACCOMODATION FORM
HOTEL LISTSAll rates are based on single / double occupany and including breakfast.
Check in
date_range
Check out
date_range

*) All price nett/night                

*) Your reservation will cancel if payment have not received after 2 weeks registration                    

*) 50% cancellation fee (as per reservation) will be charged for cancellation received after June 15, 2019    

*) 100% cancellation fee (as per reservation) will be charged for cancellation received after July 1, 2019                                        

SOCIAL PROGRAMS

After submiting this form, you will receive an email regarding your registration and terms of payment.

If you need more info please do not hesitate to contact us at nqcitra@gmail.com / +62 813-1822-0387.

Thank you.

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REGISTRATION INFORMATION

METHOD OF PAYMENT

  • Cash Onsite
  • Transfer (please copy us the bank transfer transaction in order to avoid difficulties)

PAYMENT
Payment can be made through cash or bank transfer in full amount (US Dollar / Rupiah). A Copy of bank documents must be forwarded by email together with the forms, payable to :

BANK ACCOUNT :

Bank : Mandiri Jakarta RS. Harapan Kita
Account no : 117 – 000 – 6480 – 453
Name: Perhimpunan Kedokteran Gawat Darurat Indonesia.
Branch code : 11728
Swift code : BMRIIDJA

Notes :

  • Must be paid 1 night non refundable deposit after 2 weeks reservation, the committee will cancel the reservation if not received 1 night non refundable deposit
  • Must be paid by June 15, 2019 at the list
  • Late Check Out from 12.00 WITA until 18.00 WITA will be charge at 50% off room rate, more than 18.00 WITA will be full charge
  • The reservation will be closed at June 30, 2019
  • Room cancellation should be in writing to the organizing committee, otherwise full payment will be applied and charges to the guest (Please refer to cancellation prosedure)

Indonesian participant please contact : Rani +62813 1822 0387, Ika +62896 9619 9533

CANCELLATION & REFUND
There will be a 25% charge for written cancellation made 3 months before the event. There will be a 50% charge for written cancellation made 1 months before the event and will be no refund for less more than 1 month.

ACCOMMODATION INFORMATION

HOTEL RESERVATION
The organizing committee has secure accommodation for participant. Application for accommodation must fill out the accommodation form accompanied by a non refundable 1 night deposit after 2 weeks registration balance (Full Payment) must be paid by (July 15, 2019) at the least, and otherwise the room reservation will be automatically released. This deposit is to guarantee the room with special rate provide to the symposium participants. All requests will be proceed on first come first serve basis. If certain hotel has been booked out, the Organizing Committee has the right to relocate to another hotel preference chosen. The reservation will be closed at June 30, 2019.

PAYMENT PROCEDURES
Each participant should complete the Accommodation form and email it back together with the appropriate payment receipt to symposium secretariat NQ Citra, email : nqcitra@gmail.com, attn : Ms. Ika. All payment must be paid in USD (for Overseas and non KIMS Holders) and Rupiah (for Indonesia and KIMS Holder) to :

BANK ACCOUNT :

Bank : Mandiri Jakarta RS. Harapan Kita
Account no : 117 – 000 – 6480 – 453
Name: Perhimpunan Kedokteran Gawat Darurat Indonesia.
Branch code : 11728
Swift code : BMRIIDJA

CANCELLATION
The committee will cancel the reservation if no received 1 night non refundable deposit after 2 weeks registration. 50% cancellation fee (as per reservation) will be charged for cancellation received after (June 22, 2019) and 100% cancellation on/after (July 15 , 2019)