2022 Conference Registration Surname * First Name * Middle Initial(s) Home Address: Mailing Address (if different from above) CONTACT INFORMATION: Email Address * Telephone # (work) * Mobile/Whatsapp # * Speciality Medical Qualification(s) Country * Are you a member of a Professional body or Institution? Yes No Please list: Professional Registration # Country Registered I would like to register additional person(s) for the conference. 1 Additional Person 2 Additional People 3 Additional People 4 Additional People Charges * Physician: Days 1 & 2 (US$100 each) 1 Person 2 People 3 People 4 People 5 People Physician: Day 1 ONLY (US$60 each) 1 Person 2 People 3 People 4 People 5 People Physician: Day 2 ONLY (US$60 each) 1 Person 2 People 3 People 4 People 5 People Residents / Students / Other: Days 1 & 2 (US$50 each) 1 Person 2 People 3 People 4 People 5 People PLEASE NOTE THAT EACH REGISTRANT MUST SUPPLY THEIR UNIQUE EMAIL ADDRESS IN ORDER TO BE REGISTERED. A GROUP EMAIL WILL NOT WORK FOR INDIVIDUAL REGISTRATION. Please list name(s) & Email address(es) of each Registrant(s) below (if applicable) Additional Registrant Name 1 Email Address 1 Additional Registrant Name 2 Email Address 2 Additional Registrant Name 3 Email Address 3 Additional Registrant Name 4 Email Address 4 Message (optional) Please click here for Wire Transfer Guide Once payment has been made, please forward evidence of payment ( receipt, email, picture of screen etc) ) to [email protected] as soon as possible. Conference access will be confirmed once wire transfer is received. If you are human, leave this field blank. Submit
