JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
LEVEL 1 CARDIAC CT COURSE - REGISTRATION FORM
Date: 11 - 12 APRIL 2018
Venue: NHAM Heart House, D-13A-06, Menara SUEZCAP 1, KL Gateway, No. 2 Jalan Kerinchi, 59200 Kuala Lumpur, MALAYSIA
Contact us at +603 7931 7900 or email to
secretariat@malaysianheart.org
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Title
*
Choose
Prof.
Associate Prof.
Dr.
Mr.
Ms.
Name (as per MyKad / Passport)
*
Name for printing on Certificate
Your answer
MyKad No. / Passport No.
*
For Passport, please include Country
Your answer
Contact Number (Mobile)
*
Your answer
Current Designation
*
Your answer
Place of practice / Organization
*
Your answer
Meal Preference
*
Meal will be prepared based on your preference below - please indicate one
Vegetarian Meal
Non-Vegetarian Meal
Required
Payment mode
*
Payment must be made prior to course, except payment via LPO. We DO NOT accept cash on-site. Payments are non-refundable
Choose
JomPAY (online transfer for local participants)
Telegraphic Transfer (online transfer for international participants)
LPO (Local Purchase Order / Psanan Kerajaan) - for Government only
Cheque Deposit (cheque deposit must be made prior to course)
Course Fees
*
Fee is inclusive of 6% GST
Choose
MYR 900.00 - LOCAL DELEGATES
USD 300.00 - INTERNATIONAL DELEGATES
Send me a copy of my responses.
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
