REGISTRATION FORM

ALL FIELDS ARE MANDATORY AND MUST BE COMPLETED IN BLOCK LETTERS

Erine Mok
Attention Booking Date:

VIP Code: Event Code: P146239

Event Name: 4th Electronic Health Records 2014
Delegate 1 Details: Delegate 3 Details:
Name: Mr Ms Name: Mr Ms
Job Title: Job Title:
Mobile No: Mobile No:
Department: Department:
Email Address: Email Address:
Tel No: Tel No:
Fax No: Fax No:
Delegate 2 Details: Delegate 4 Details:
Name: Mr Ms Name: Mr Ms
Job Title: Job Title:
Mobile No: Mobile No:
Department: Department:
Email Address: Email Address:
Tel No: Tel No:
Fax No: Fax No:
Company Details
Company Name:
Full Company Mailing Address:
Email Address of Approving
Name of Approving Manager:
Manager:
Title of Approving Manager:
Name of Contact Person:
Email Address of Contact Person:
(Person Who Arranged Registration)
Title of Contact Person: Contact Number of Contact Person:
Name of Human Resources or Email Address of Human Resource
Training Manager: or Training Manager:
Conference Package ( please indicate delegate number on your selection )
3 Day Package
4 Day Package (2 day conference + 2 Day Package ( ) Industry rate
(2 day conference + - 1PRE Workshops (2 day conference
PRE & POST OR ONLY) ( ) Hospital, Institutes
workshop) & Government Rate
-1 Post workshop
Payment Details ( Please tick an option below )
A confirmation letter and invoice will be sent to you upon receipt of your registration form. Please note that payment must be received before the
event date.
Credit Card Bank Transfer Cheque ( Payable to IBC Asia (S) Pte Ltd)
FOR CREDIT CARD PAYMENTS ( VISA/ MASTERCARD/ AMEX)
Please fax back the credit card authorisation form to +65 65082406. As we treat your credit card information in the strictest confidence,
please do not send payment details by email.

Cancellations:
Should you be unable to attend, a substitute delegate is welcome at no extra charge. Cancellations must be received in writing at least 10 business days before the start of the
event, to receive a refund less 10% processing fee per registration. The company regrets that NO REFUND will be made available for cancellation notifications
received less than 10 business days before the event.

Data Protection:
The personal information entered during your registration/order, or provided by you, will be held on a database and may be shared with companies in the Informa Group in the
UK and internationally. Sometimes your details may be obtained from or shared with external companies for marketing purposes. If you do not wish your details to be used for
this purpose, please contact Winnie Seah (database) at Winnie.seah@ibcasia.com.sg or Tel: +65 6508 2468 or Fax: +65 6508 2408

FOR OFFICAL USE ONLY:

Invoiced amount: Confirmed by: