REGISTRATION FORM ONLINE

INTENSIVE COURSE IN ABDOMINAL RADIOLOGY
19th.-23rd. September 1999

1. Name:

2. Address


3. Institution and Department

4.  Tel no:

5.  E-mail:

6.  Computer knowledge:
Excellent (10-9)   Very Good (8-7)   Good (6-4)    Fair (3-1)   Nil(0)

7. Internet usage: (please specify purpose: e-mail, radiology CME Homepage, general topics, ...  )

Very Regular  (>5x/week)   Regular (3-4 x/week)   Moderate (2x/week)  Fair (few/month) Nil

 
Registration Fee
Professionals                                           RM 100
Postgraduate student                               RM 100
Auxillary staff, Student & technologist      RM 50

 Cheque or Bank draft should be made payable to
 "Timbalan Bendahari USM"
  Enclosed cheque No: 
  Bank: 

 Please send your cheque to :
The Secretariat
Intensive Course In Abdominal Radiology
Department of Radiology
School of Medical Sciences, 
Universiti Sains Malaysia
16150 Kubang Kerian, Kelantan.

 

8. Reservation for House Officer Hostel (only limited places available)

Check-In date : 

9. Reservation for Perdana Hotel (for special discount price as noted)

Check-In date : 

*Thank you for your registration. Have a Nice Day.