Step 4 - Singapore General Hospital

Singapore General Hospital & Wound Healing Society (Singapore)
1st Joint Asia Pacific Wound Conference
1 - 3 September 2011
Mandarin Orchard Singapore, 333 Orchard Road
The Yin and Yang in Wound Healing
REGISTRATION FORM
Please submit the completed registration form and payment to:
c/o Ms Tan Cheo Tee
Department of Nursing
Singapore General Hospital
Bowyer Block B Level 2
31 Third Hospital Avenue
Singapore 168753
For enquiries, please contact Ms Tan Cheo Tee at :-
Tel: (65) 63266001 Fax: (65) 63214840
E-mail:tan.cheo.tee@sgh.com.sg
For more information, please go to
www.sgh.com.sg/ACW2011 or www.whss.org.sg
Step 1:-Registration Detail
Prof/Dr/Mr/Mrs/Ms
Given Name
Department
(Family Name)
Designation/Speciality
Institution
Mailing Address
Tel:
Email:
Certificate of Attendance
(For Full Conference only):
Fax
MCR/SNB No:
(applicable to local doctors & nurses)
Not Required
Required (please print your name as it should appear on the certificate)
Special requirement for dietary :
Vegetarian
Food served non-pork, non-lard
Step 2:- Registration Fee
(Fees shown are in Singapore dollars inclusive of GST)
Category
Early Bird Registration
before 30th July 2011
Registration after
30th July 2011
Full Conference $350.00 $400.00
WHSS Member Full Conference $300.00 $300.00
One-day Registration
Please indicate Day 1 Day 2 Day 3
Two-day Registration
Please select two days
Day 1 Day 2 Day 3
Accompanied Person
(Excludes Conference and Workshops Attendance)
Number of accompanying person __________
$150.00
$300.00
$120.00
Step 3:-Selection of Workshop
You are only allowed to attend 4 workshops on Day 2 (i.e. on 2nd September 2011)---Please make your select below
Day 2 workshops are limited to 65 participants per workshop, on a first-come; first-served basis.
Basic Assessment for Vascular Leg Ulcer
Compression Bandaging
Wound Care for Vascular Leg Ulcer
Others Adjunct/Advanced Therapies for Leg Ulcers
Techniques of repositioning and transferring of paraplegic patient after surgery
Wound fistulae and tube / drains care after Surgery
Support Devices for Decubitus Ulcer
Burn Wound Dressing

Step 4:- Payment inclusive of GST
Total Payment Due (Include GST) $
Cheque in Singapore Dollars:
Cheque No.:
Bank:
All Payment are to make payable to "Singapore General Hospital Pte Ltd"
Please include the following payment details on the reverse side of the cheque :
"Registration fee for Joint 1 st Asia-Pacific Wound Conference 2011 (IO ref 51305022), participant's name and
institution"
Step 5:-Telegraphic Transfer
Bank
Reference No.
Amount(SGD)**
** Payment made by Telegraphic Transfer should be made nett of all bank charges and commissions
Please state "Registration fee for Joint 1st Asia Pacific Wound Conference 2011 (IO ref 51305022), participant's name and Institution" when
making payment
Bank Name: DBS Bank Ltd Bank Code : 7171
Branch Name : Great World City Branch Branch Code : 032
Bank Address : 1 Kim Seng Promenade #02-32, Singapore 237994
Account No. : 032-001600-6
Swift Code : DBSSSGSGXXX
Step 6:- Credit Card Payment - By Visa or Master Card only
Card Type
Card Number
Security Code*
Mailing Address#
VISA CARD
MASTER CARD
Expiry Date (MM/YY)
* Security Code
The card security code is a unique three or four digit number printed on your debit/credit card. The number is not embossed on the card so
that it cannot be printed on receipts - making it difficult for anyone other than the genuine cardholder to know it. Some cards, issued in UK
may have the security number printed at the top of the signature strip on the reverse of the card.
#Cardholder's mailing address
This should be the address to which your card statement is sent. It must match the address held by your card issuer exactly. If it does not,
the retailer may decline your purchase, or defer acceptance of your payment and seek further proof of your address.
This is to certify that I
(credit cardholder's name),
hereby authorise Singapore General Hospital Pte Ltd to charge a total amount of SGD $
to the above credit card for payment of 1st Asia-Pacific Wound Conference 2011 from 1-3 September 2011.
(cardholder's signature)
(Date)
Confirmation of Registration
Closing date for early bird registration is 30 July 2011.
Closing date for normal registration is 15 August 2011.
Registration will be confirmed when payment is received and processed. Acknowledgement in writing with confirmation of your requirements
according to your registration form will be sent to your email address, unless otherwise advised. Official receipt will be issued upon attendance.
Cancellation Policy.
Participants who are unable to attend the conference after registration are most welcome to nominate a substitute. Please advise the secretariat in
writing as soon as possible. Fifty percent of the registration fees will be refunded only under exceptional circumstances. No refunds will be given
after 30 July 2011.