REGISTRATION FORM

SEGERA REGISTRASI SEKARANG UNTUK EARLY REGISTRASI

Please mark ✓ on the Workshop / Symposium / Accommodation you choose

Please mark ✓ on the Workshop you choose

Accomodation

Subtotal hotel:

Subtotal hotel:

Subtotal hotel:

Total: Rp.

CANCELLATION AND REFUND POLICY

Written cancellation notice is required. Cancellation must be received before March 1st 2019 a 50% refund will be returned after congress ended. No refund will be allowed thereafter.

PAYMENT BY :
Bank Name : BTPN Branch Menara BTPN Jakarta
Account Number : 0537.3.002323
Account Name : GPDI-PEDIATRIC CARDIOLOGY UPDATE 7
Bank Code : 213
Swift Code : BTPNIDJA

THIS FORM TOGETHER WITH THE REQUISITEMENT PAYMENT AND/OR DOCUMENTATION SHOULD BE
EMAILED/FAXED TO SECRETARIAT :

GEDUNG IDAI PALEMBANG
Jalan Sintraman Jaya II Palembang, South Sumatera Indonesia
Email : pcu2019palembang@gmail.com