4 - 5 AUGUST 2009 BARIATRIC & METABOLIC SURGERY WORKSHOP 2009 Division of Upper GI Surgery Department of Surgery The Chinese University of Hong Kong CUHK Jockey Club Minimally Invasive Surgical Skills Centre Organizers : * REGISTRATION FORM Payment Method (This part must be completed for acceptance of registration) A bankdraft / cheque for USD / HKD made payable to “The Chinese University of Hong Kong” is enclosed. (Personal cheques are acceptable for HK residents) Please debit my credit card: Type: Visa / Master Name : Card No. : Expiry date : Signature : Cancellation & Refund Policy - All cancellations must be made in writing to the Secretariat. - The following refund policy will be observed: - Postmarked, faxed or email on or before 28 Jul 2009 — 50% of the amount paid - Postmarked, faxed or email after 28 Jul 2009 — No Refund Live Demonstrations & Lectures – Doctor HK$2,000 / USD 250 Live Demonstrations & Lectures – Health Professionals / Nurse / Dietitian HK$800 / USD 100 Live Demonstrations, Lectures & Hands-on Workshop HK$10,000 / USD 1,250 Registration Fee BARIATRIC & METABOLIC SURGERY WORKSHOP 2009 4 - 5 August 2009 Title: Prof. Dr. Mr. Ms. First Name: Last Name: Position: Institution: Mailing Address: Country: Tel: Email: Fax: Course Director Dr. Simon KH WONG Consultant Department of Surgery Prince of Wales Hospital Co-Director Prof. Enders KW NG Professor and Chief of Upper GI Surgery Department of Surgery Director of CUHK Jockey Club Minimally Invasive Surgical Skills Centre Prince of Wales Hospital The Chinese University of Hong Kong Overseas Faculty Dr. Muffazal LAKDAWALA Consultant Surgeon Chief of Department of Bariatric and Minimal Invasive Surgery Saifee Hospital, Mumbai, India Prof. Wei Jei LEE Chairman Asia-Pacific Bariatric Surgery Society Local Faculty Prof. Alice PS KONG Associate Professor Department of Medicine & Therapeutic, Prince of Wales Hospital The Chinese University of Hong Kong Dr. Wilfred LM MUI Consultant Surgeon Hong Kong Bariatric & Metabolic Surgery Institute Ms. Phyllis YP YAU Dietitian Dietetic Department Prince of Wales Hospital Registration - By fax or by mail - Please complete the registration form and return it with appropriate fee to the Secretariat. Vacancies on the course is limited. Participants will be registered on first-come-first served basis upon full payment of registration fee. BARIATRIC & METABOLIC SURGERY WORKSHOP 2009 Sponsored by : Johnsons & Johnsons Karl Storz Endoscopy China Ltd.