4thWorld Chinese Otorhinolaryngology-Head & Neck Surgery Conference

Multidisciplinary and Individualized Management

13-15 June 2013

Hong Kong Convention and Exhibition Centre

REGISTRATION FORM

Registration method
Complete this registration form in BLOCK LETTERS and return with the appropriate registration fee to the Secretariat.

Participant’s Information
Salutation: /  Professor  Doctor  Mr.  Ms.
Surname: / Given Name:
Position: / Department:
Institution:
Mailing Address:
Region:
Tel: / Fax:
Email:

conference secretariat

Department of Otorhinolaryngology, Head and Neck Surgery
The Chinese University of Hong Kong
Prince of Wales Hospital, Shatin, Hong Kong

Tel: (852) 2632 1277

Fax: (852) 2145 8876

Email:

use of personal information

The Department of Otorhinolaryngology, Head and Neck Surgery of The Chinese University of Hong Kong (“Department”) intends to use the name and contact details of conference participants for direct marketing purposes relating to solicitation of donations, organizing, coordinating and carrying out activities to support or encourage charitable and/or health related works by the Department.

Please write to the Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong if you wish to object to the use and/or provision of your personal data for direct marketing purposes.

Registration category

Main Conference (14-15 June 2013)
On/Before 30 April 2013 / After 30 April 2013
 / ENT Specialist / HK$3,500 / US$450 / HK$4,500/ US$580
 / Nurse, Trainee and Allied Health Professions / HK$2,250 / US$295
Fellow and/or Member of Supporting Organizations: **
On/Before 30 April 2013 / After 30 April 2013
 / ENT Specialist / HK$3,150 / US$405 / HK$4,050 / US$525
 / Nurse, Trainee and Allied Health Professions / HK$2,050 / US$265
Others
 / Accompanying Spouse
(fee includes conference, lunch and refreshment) / HK$2,000 / US$260 per person
Grand Total / HK$

Remarks:

* / Registration Fee includes registration, lunch and refreshment.
** / Supporting Organizations includes: The Hong Kong College of Otorhinolaryngologists, The Hong Kong Society of Otorhinolaryngology, Head & Neck Surgery, Hong Kong Society of Audiology, The Hong Kong Association of Speech Therapists, Society of Otolaryngology, Head & Neck Surgery Singapore, Taiwan Otolaryngological Society.

Payment Method

 A bank draft for USD/HKD made out to “The Chinese University of Hong Kong” is enclosed.

(Personal cheques are acceptable for HK residents ONLY)

 Please debit my credit card: Type: Visa / Master* (*delete as appropriate)

Name ______

Card Issuing Bank ______

Card No.: ______- ______- ______- ______Expiry date ______/ ______

Amount USD/HKD ______

Signature ______Date______

Bank transfer

Account name: / The Chinese University of Hong Kong
Name of bank: / Hang Seng Bank Limited
Address / Kowloon Main Branch, 618 Nathan Road, Kowloon, Hong Kong
HKD Account No.: / 293-005005-001
Recipient: / Department of Otorhinolaryngology, Head and Neck Surgery, CUHK
Project code:7104193 / Swift code:HASE HKHH / Chips no.:010522 / Bank code:024

Payment, Cancellation and Refund Policy

Please note that full payment must be received with completed registration form.

All cancellations must be made in writing to the Secretariat. The following refund policy will be observed:

Postmarked, faxed or email on or before 30 April / Refund of registration fee less an administration charge of HK$450
Postmarked, faxed or email after 30 April / No refund

Should the Conference scheduled have to be cancelled due to unforeseeable circumstances, the organizer shall try to reschedule the programme whenever possible. There will be no refund if the delegate cannot attend the re-scheduled programme. If, for reasons beyond the control of the Organizing Committee, the Conference is cancelled, registration fees will be refunded after the deduction of conference expenses already incurred.

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