PARTICIPANT DETAILS: (Please type or write your particulars in BLOCK letters and REGISTRATION FORM Full Name: Organisation: Title: Mr. Ms. Mrs. Miss Prof. Dr. other:_______________________ Affiliated Organisation/ Institution: Address: Postcode:______________ Country:___________________ Contact Number : Offi ce Mobil e Fax E-mail: MAPS Membership: Yes, Membership Number:________________________ No membership Participant Type: I wish to attend the conference as a participant I wish to make a presentation I am an Exhibitor Presentation Oral Poster (Size: A1) Presentation Title: Early Registration Fee (before 30 th June 2017) Standard Registration Fee (after 30 th June 2017) Registration Fee: Student (member) MYR 500 MYR 600 Registered MAPS Member MYR 750 MYR 850 Non-member MYR 950 MYR 1050 International Student USD 200 USD 250 International Delegate USD 300 USD 350 Meal Choice Non-Vegetarian Vegetarian Conference Dinner Yes No Mode of payment: Cash Bank draft/ Cheque (for Malaysian only) Bank Draft Number/Cheque Number:____________________ Issuing Bank:________________________ Date of Transaction:____________________ Bank transfer (for Malaysian only) Transfer Receipt Reference Number:_____________________ Issuing Bank:________________________ Date of Transaction:____________________ Bank Cheque (for Malaysian only) Cheque Number:____________________ Issuing Bank:________________________ Date of Transaction:____________________ Local Order (for Malaysian only) LO reference No.:_____________________________ Telegraphic Transfer*: (T.T. Reference No.:____________________ T.T. Bank: __________________________ Date of Transaction:____________________ )