Registration Form

for all inquires: (+603) 4023 4700 (+603) 4025 4700

Fields marked (*) are compulsory

A: PERSONAL PARTICULARS
Salutation: * Prof A/Prof Dr Mr Mrs Ms		Gender: * Male Female
Full Name: *		Date of Birth: *
Correspondence Address: *
State: *	Country: *	Postal Code: *
Contact Number: *	Mobile Number: (Optional)	Facsimile Number:
Email Address: *	Institution: *	Specialty: *
Are you the APOA/APSS Existing Member?: * Yes No
B: REGISTRATION FEES
Category		Amount Payable
International Surgeon (APSS Member)		USD 300
International Surgeon (Non-APSS Member)		USD 400
International Surgeon form Reduced Rate Countries (APSS Member)		USD 200
International Surgeon form Reduced Rate Countries (Non-APSS Member)		USD 300
TOTAL (USD)

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