REGISTRATION FORM (INTERNATIONAL)

Last Name First Name Title _______Dr.

Middle Name __________Prof.

________________________________________ ________Ms
__________Mr.

Gender _______Male_______ Female Email address

Affiliation/Institution

Position Held
Postal Address

Food Preference
No restriction _______ Vegetarian _______ Halal _______
Registration Early bird (up to March On Site (May to June
Fee* 31, 2011) 2011)
_______Pharmacis 9,000 pesos 11,000 pesos
t
_______Student** 7,000 pesos 9,000 pesos
*Participant is entitled to Conference ID, Kit, snacks and lunch for 2
days, Welcome Reception and Fellowship dinner, entrance to company
exhibit area and certificate of attendance with CPE credit units.
**Student participant must submit school certification. For
undergraduate students only.

Payment Instruction

All payment must be deposited to the Account Name: PHILIPPINE

PHARMACISTS ASSOCIATION with ACCOUNT NO. 0341-020561-003 at
SECURITY BANK CORPORATION, Mendiola Branch at Mendiola Street,
Manila , Philippines. The SWIFT Code is SETCPHMM and the CHIPS ID
NO. 010-457. All bank charges must be to the account of the payor
(participant).

Date of Payment _____________________________________

Amount ____________________________________________
Bank of Origin_______________________________________
Address____________________________________________