Asian Cities Against Drugs

Registration Form

IMPORTANT: Please fill in block capital. Do not omit any particulars.

	FULL NAME (as in International Passport)	:
	DATE OF BIRTH (D/M/Y)	:		COUNTRY OF BIRTH	:
	SEX	:
	MARITAL STATUS (SINGLE/MARRIED)
	PASSPORT NUMBER	:
	NAME OF ORGANIZATION	:
	OFFICE ADDRESS	:			:
	ZIP CODE	:		TEL. NO	:
	EMAIL	:		FAX NO	:
	POSITION/JOB TITLE	:		DATE OF DEPARTURE & TIME	:
	DATE OF ARRIVAL & TIME	:		AMOUNT PAYABLE	:
	NUMBER OF DELEGATES	:			:
	ENDORSED HERE WITH A CHEQUE / DRAF NO	:

 

In Favour of: MBMB A/C No. : RHB Bukit Baru 25401300007581

*The fee for attending this conference is RM200.00 for Malaysia participants adn USD100.00 for participants from outside Malaysia

Confirmation of participant:

1. Please fax registration form at +606-2317208 or email at mbmb.ascad09@yahoo.com or send by mail.

2. Upon receipt, the secretarial shall reconfirm your participant.

3. Kindly return this form to secretariat by 23th January 2009