REGISTRATION FORM

Course Title : BASIC VESTIBULAR REHABILITATION Date : 19th-20th Nov 2011 & 3rd Dec 2011 Cost Fee : SGD$ 720 (SGD$ 600 for SPA members)
Participant Name Profession : : ( Dr Mr Mrs Ms)

SPA No. : (for physiotherapists only)

Organisation Name : Country Email Fee Payment

Registration Please send the completed registration form before 20th Oct 2011 by any of the following methods: By Post Attn: Ms See Yin (Executive Assistant), 6357 8363 Physiotherapy Department (Level 2 NNI Block), Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433

: : : Cheque no. (Amount : )

Tel. No.

Mobile No. : Fax No. :

By Fax : 6357 8306

By Email: AHINet@ttsh.com.sg Please note that registration will only be confirmed (on a first-come-first-served basis) upon submission of duly completed registration form and receipt of full payment. Participants will receive a confirmation email upon successful registration. Payment Crossed cheque must be made payable to: TAN TOCK SENG HOSPITAL PTE LTD Please state that the payment is for BASIC VESTIBULAR REHABILITATION and indicate your Name and Contact number clearly on the reverse of the cheque. Receipt will be given on the course day. Cancellation Any cancellation or replacement must be conveyed to AHINet in writing. A cancellation fee of 50% of registration fee will be charged if cancellation is received before closing date. There will be no refund of registration fee for cancellation on or after closing date. AHINet reserves the right to cancel the workshop and fully refund the registration fee should unforeseen circumstances necessitate it.