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Delegate Registration

The 5th Asian Federation of Laboratory Animal Science Association Congress 10-12 October 2012, Bangkok, Thailand Registration Number: DELEGATE INFORMATION

Title (Please tick) Dr. Mr. Mrs. Ms. Other (please specify) .. First Name: Ganendra Middle Name: Awang Last Name: Kristandya Department or Institute: Faculty of Veterinary Medicine Brawijaya University Position: Student P o s t a l A d d r e s s : J l M t H a r y o n o N o 1 6 9 C i t y : M a l a n g C o u n t r y : I n d o n e s i a P o s t a l C o d e : 6 5 1 4 5 E - m a i l : p s k h _ u b @ u b . a c . i d P h o n e : + 6 2 3 4 1 5 7 3 6 4 2 F a x : + 6 2 3 4 1 5 7 3 6 4 2 Special Dietary: Vegetarian Halal Food Others (please specify)
SUBSCRIPTION TYPE Special Rate Pre-Registration (September 1 - 15, 2012) 7,000 THB. 8,000 THB. 3,500 THB. 3,500 THB. 25,000 THB.

Categories Member Non-Member Student Accompanying Person Diamond Package

Early-Bird (before August 31, 2012) 6,000 THB. 7,000 THB. 3,000 THB. 3,000 THB. 25,000 THB.

Pre-Registration (September 16 - 30, 2012) 8,000 THB. 9,000 THB. 4,000 THB. 4,000 THB. 25,000 THB.

On-Site Registration 9,000 THB. 10,000 THB. 4,500 THB. 4,500 THB. 30,000 THB.

Special Program on October 11, 2012 One Health Stream Only (Limited number by pre-registration, up to 120 seats) SOCIAL PROGRAM Categories Opening Ceremony Welcome Dinner Thai Night Closing Ceremony Date Oct. 10 Oct. 10 Oct. 11 Oct. 12 Additional Cost (THB.) Free of charge Free of charge 800 THB./Person Free of charge Free of charge

TOTAL PAYMENT

Grand Total

3,800

THB

Note: All bank charge/handling fee are to be responsible by register person.

ACCOMPANYING DETAIL

Title (Please tick) Dr. Mr. Mrs. Ms. Other (please specify) ... First Name: .. Middle Name: ..... Surname: .. ....... Department or Institute: Position: ...... Postal Address: ... City: . Country: ..... Postal Code: .. E -mail: ..... Phone: Fax: .... Special Dietary: Vegetarian Halal Food Others (please specify) .........
PAYMENT

Wire Transfer: Bank Detail Branch Account Name Bank Code Bank Address Bank of Ayudhya Tesco Lotus Salaya TALAS/AFLAS AYUDTHBK 99/14 MU 1, Borommaratchachonnani Road, Bang Toey, Sam Phran, Nakhon Pathom 73210 Telephone: +66 2482 2100-2

Account Number 614-1-06198-3

Cancellation and Refund Policy Notification for cancellation must be in writing to the secretariat. Please send your registration information to registration@aflas2012.org. All refunds will be made after the congress for administrative reasons. Handling fees and bank charges will be deducted from the refund amount. Before August 31, 2012 After September 1, 2012 50% Refund No Refunds will be made

Applicants signature: Ganendra Awang K Date: 31 August 2012

After making the transfer, please send a copy of bank receipt of your remittance to registration@aflas2012.org or fax +66 (0) 2749 3950 Ext. 3123