Registration Form

Copy this form, fill in your particulars and send it back to us in an email with heading 'Registration' to : speechlanguagehearingconf2010@gmail.com

Registration Form

Name (Mr., Ms, Madam, Dr., Prof., etc) :

Address :


Postcode:

Institution / Affliation :

Tel. no:

Fax. No :

Email :

Gender :

Type of participation. Please tick appropriately :
Presenter = ___ (local) ____ (International)
Participant = ____ (local) ___ (International)
Student = ____ (local) _____ (International)

Please register me for Preconference workshop : ____

Please register me for conference dinner : _______

Diet Preferenc : vegetarian ___ Non-Vegetarian ___

Conference Registration Fee :

International participants : USD 350
Local participants : RM500
Local students : RM150
International Students : USD 100

Pre-Conference Workshop Registration Fee :

Local Participant : RM200
International participant : USD 60
Student Fee : RM100
International Student : USD 30

Dear Sir,

I, ________________________ (name) am remitting to you a bank draft


No : ___________ (Bank ________________) the amount (RM/USD) __________


(in words: _________________________) being total in payment of costs that i have


indicated above.

Please make bank draft to payee : UKM Kesihatan Sdn Bhd.

To finalize regisration :

(a) Please send your bank draft payment to :

UKM Kesihatan Sdn Bhd

(Attn: Asia Pacific Speech Language Hearing Sciences 2010)

7th Floor, UKM Medical Center

Jalan Yaakob Latif

Bandar Tun Razak

56000 Cheras

Kuala Lumpur

Malaysia

(b) Send an email with registration particulars to speechlanguagehearingconf2010@gmail.com.

Should you have further queries, please email us at the above.

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