MEDICAL DEVICES BETC SYMPOSIUM 2013

Credit Card Name: _____ Option: Visa MasterCard Credit Card No.: - - - Security Code (on ... 2 College Road Level 2, Alumni Medical Centre Singapore 1...

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MEDICAL DEVICES BETC SYMPOSIUM 2013

Date: 11 & 12 January 2013 (Friday & Saturday)

Contact person: Denise Tan

Time: 8am – 6pm

Tel : 62231264 Email : [email protected] Fax : 62247827 Address: Singapore Medical Association 2 College Road Level 2 Alumni Medical Centre Singapore 169850

Venue: Matrix Auditorium (Level 2) 30 Biopolis Street, Singapore 138671 Registration fees: $250 (inclusive of 7% GST)

• Specially for SMA / SDA members CME & CPE points pending

I would like to sign up for the BETC SYMPOSIUM 2013 – Engineering in Medical Devices on 11 – 12 January 2013. Name: Prof/ AProf/ Dr ___________________________________MCR No: ___________________ Handphone: ____________________________ Office Tel: _______________________________ Email: __________________________________________________________________________ Mailing address: __________________________________________________________________

 General Practitioner

 Specialist, specialty: _______________________________________

 SMA Member

 Non-SMA Member

 SDA Member

 Non-SDA Member

Payment Mode Total Cost: S$250.00 A) By Credit Card (VISA / MasterCard only). Credit Card Name: _________________________________

Option:

 Visa  MasterCard

--- Security Code (on reverse of Card):  Card Expiry Date: / (month/year) Credit Card No.:

Signature: __________________________________

Date: __________________

B) By Cheque: payable to “Singapore Medical Association” Please mail form and cheque to: Singapore Medical Association (Denise Tan) 2 College Road Level 2, Alumni Medical Centre Singapore 169850 Registration is not confirmed until payment is received.