SAUDI ARABIA CHAPTER

1st ACP Saudi Arabia Chapter Congress

Medicine 2014
11 12 May 2014
Alfaisal University | Riyadh | KSA

Registration Form
Please complete the registration form and fax/email to MCI Middle East LLC
Fax No: + 971 (0) 4 311 6301 | Email: acp-ksa@mci-group.com
You can also register online at www.acp-ksa.com

Personal Details
Title:

Prof.

Dr.

Mr.

Ms.

Mrs.

Miss

Other

First name(s):_____________________________________________ Last name: __________________________________________

Company: _______________________________________________ Nationality: _________________________________________
Address: ___________________________________________________________________________________________________
City: ___________________ State: _________________Country: ________________________ Postal / Zip Code: __________________
Phone : _________________________________ Mobile: ____________________________ Fax: _____________________________
Email: _____________________________________________________________________________________________________

Accompanying Persons (Spouses / Partners) do not have access to the plenary sessions, workshops, coffee breaks & lunches.
Title

First name

Last name

1.
2.

Congress Registration
ACP Members
*ID. No.:

Early Bird Registration

19 Jan 2014 - 31 March 2014

Late Registration
1 April 2014 - 4 May 2014

Onsite Registration
11 - 12 May 2014

Physicians

SAR 500 ($ 135)

SAR 600 ($ 165)

SAR 700 ($ 190)

Residents & Fellows

SAR 400 ($ 110)

SAR 500 ($ 135)

SAR 600 ($ 165)

Medical Students

SAR 200 ($ 55)

SAR 300 ($ 80)

SAR 400 ($ 110)

Non-Physician
Health Care Professionals

SAR 300 ($ 80)

SAR 400 ($ 110)

SAR 500 ($ 135)

SAR 600 ($ 165)

SAR 700 ($ 190)

SAR 800 ($ 215)

Non-ACP Members
All Categories

*Please provide your ACP 8-digit Membership ID Number.

Registration fee includes:
Attendance to congress sessions
Entrance to the exhibition
All congress documents
Coffee breaks & lunches
For administrative purposes, a copy of your certificate is required as a proof in order to avail of the registration fee.

Total Registration Fees

Workshops
Workshops
Workshop 1: Musculoskeletal Exam
Workshop 2: Difficult Airway

Date

Time

_________________USD

Fees per Session (per person)

Sunday

16:00 18:00

SAR 500 ($ 135)

11 May 2014

16:00 18:o0

SAR 500 ($ 135)

Total Workshop Fees

_________________USD
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Congress Secretariat: Tel: +971 4 311 6300 / Fax: +971 4 311 6301, Email: acp-ksa@mci-group.com

Terms & Conditions

Registration is conrmed only upon receipt of payment.
Registration fee applies as per the date of payment.
If the payment is made within 10 days of the event date, a proof of payment or a credit card/letter of guarantee will be required.
Should your payment not be received 10 days prior to the event date, the Event Organizer reserves the right to cancel your pre-registration.
If you cannot attend the event, we are happy to accept a substitute delegate until 31 January 2014. After this date, name changes can only be coordinated
onsite with a fee of SAR 100.00 per name changed.
The Invoice currency for your registration will be in Dollar

Sub - Totals
Sub Total Registration

USD

Sub Total Workshops

USD

Total Payment Required

USD

USD

GRAND TOTAL
Payment Mode 1

Bank Transfer

Beneficiary

MCI Middle East LLC

Account Number (USD)

1021233252602

IBAN (USD)

AE280260001021233252602

Bank

Emirates NBD

Address

P.O. Box 11954, Al Suk Branch, Dubai, U.A.E.

Swift Code

EBILAEAD

Phone

+ 971 4 35 33 545

* Please indicate your name, your reference number and ACP KSA 2014 against remmitance reference enabling our bank to accurately locate your payment

Payment Mode 2

Credit Card Payment Authorization

Only Visa and MasterCard are accepted.

I hereby authorize MCI Middle East LLC to debit my credit card as follows
Visa

MasterCard

Credit card number:

Credit Validation code (3 digits on reverse of your credit card):

Expiry Date:

Grand Total USD:

Credit card holders name (please print): _______________________________________________________________________________

Signature: _____________________________________

Date: ______________________________________________________

Please fax or email a copy of both sides of the credit card including your passport copy to: MCI Middle East LLC P.O. Box 124752, Dubai. Fax: +971 4 311 63 01.
Email: acp-ksa@mci-group.com
Payments settled in SAR according to the exchange rate of the day when the above credit card is debited by MCI.

Contact Details
MCI Middle East LLC (Congress Secretariat)
Address: P.O. Box 124752 | Dubai, United Arab Emirates
Phone: + 971 (0)4 311 6300 | Fax: + 971 (0)4 311 6301
Email: acp-ksa@mci-group.com | Website: www.acp-ksa.com

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Congress Secretariat: Tel: +971 4 311 6300 / Fax: +971 4 311 6301, Email: acp-ksa@mci-group.com