9th National Dental Students’ Scientific Conference
5thMay 2017
“Inspire, Integrate, Innovate”

A. DELEGATES INFORMATION
Title (Please ✓): / □Professor / □Dato / □Datin / □Dr / □Mr / □Mrs / □Ms
Full name:
University/Institution:
I/C /Passport no.:
Mailing Address:
Postal Code: / City: / State:
Tel no: / Fax no: / Email:
Please indicate your registration ✓ Registration to be made by 1st April 2017
WORKSHOP / REGISTRATION FEE
STUDENTS / ALUMNI/ OTHERS
1. Diode Laser
(Max 30 pax)
Time: 9am – 1pm
Venue: Penang International Dental College / MYR 75.00
□ / MYR 300.00
□
2. CBCT –An Interactive Workshop
(Max 30 pax)
Time: 9am – 1pm
Venue: Penang International Dental College / MYR 60.00
□ / MYR 100.00
□
3. Wiring Techniques for Closed Reduction of
Maxillomandibular Fracture
(Max 30 pax)
Time: 9am -1pm
Venue: Penang International Dental College / MYR 60.00
□ / MYR 200.00
□
Disclaimer:
Registration is limited and will be taken on a first come first serve basis.
All rates are inclusive of 6% GST.
All fees inclusive of refreshment, certificates of participation, course hand-outs, hands-on experience.
On-site registration is not available.
B. PAYMENTS AND REGISTRATION
(Please tick (✓) where appropriate)
Enclosed is my total payment of RM / to be made through:
□ / Cheque/Bank Draft
Cheque No/Bank Draft No.:
Issuing Bank: /
□ / Cash Deposit/ Online Banking
Reference no.:
Payer a/c no:
Bank: /
Please make bank draft/cheque payable to
Bank Name: Ambank (M) Berhad
Account No: 232-2012-000212
Payee name: VIS Professional Portfolio Sdn Bhd
Please email the duly filled in registration form along with the copy of bank-in slip/ transfer receipt to

C. DECLARATION
I declare that I have read and understood the terms and conditions relating to the 9TH NATIONAL DENTAL STUDENTS SCIENTIFIC CONFERENCE 2017 for which I wish to apply and I now confirm that to the best of my knowledge all the information given in this form is a true statement of fact.
  1. Registration Policy
    The registration form is for one delegate only and is not transferable to another person.
    Registration is only valid when payment is received in full.
The organizing committee reserves the right to change or cancel the programme without prior notice.
An acknowledgement email will be sent once the payments are received.
  1. Indemnity
    NDSSC 2017 will not be responsible for any accidents/injury/loss or damages that may occur to delegates on the way to and /or fro to the conference or during and after the conference.
  2. Cancellation/Charges and Refunds Policy
    Any cancellation of registration must be made in writing to the Secretariat of 9TH NDSSC 2017.
    There will be 50% refund of registration fee for cancellation made before 1st April 2017.
    There will be no refund of registration fee for cancellation made after 1st April 2017.
  3. Liability Limitations: NDSSC 2017 is not liable for any damages / losses caused by the individual.

Signature of Delegate
(Name)
(Ic no.)

D. DEAN’SAUTHORIZATION ( For Student delegate only )
I hereby acknowledgethat the studentdelegate mentioned above represent our institution and they are allowed to attendthe 9th National Dental Student Scientific Conference.
Signature of Dean
(Date)
E.CONTACT US
For further enquiry, please email .