A. PERSONAL DETAILS
Title
Select Title
Prof
Dr
Datuk
Dato'
Datin
Mr
Mdm
Ms
Name On Badge
* Limited to 15 letters only
Full Name as per IC / Passport
IC Number
Institution / Hospital
Correspondence Address
City
Postcode
Country
Select Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte dIvoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican
Republic
Ecuador
East Timor
Egypt
El Salvador
England
Equatorial Guinea
Eritrea Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Great Britain
Greece
Grenada
Guatemala
Guinea
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Ireland
Oman
Pakistan
Palau
Palestinian State
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
St. Kitts & Nevis
St. Lucia
St. Vincent & The Grenadines
Samoa
Saudi Arabia
Scotland
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Sahara
Wales
Yemen
Zaire
Zambia
Zimbabwe
Letter for Visa Application
Mobile Number
(country code)(area code)(telephone no)
Fax
(country code)(area code)(fax no)
Email
Profession
Dietary Requirement
B. INSTITUTION / COMPANY SPONSOR DETAILS
* If you are registering for yourself, please go to part C
Contact Person's Name
Institution / Company Name
Mobile Number
Office Number
Email
* Institution / Company Sponsor details are compulsary if you are a sponsor and would like to be kept updated on registration.
C. REGISTRATION FEES
Please select the relevant option.
DATES
CATEGORY
MASM Member
(Life Member & Ordinary members in good standing only )
Non-MASM Member (Malaysian) & ASEAN Countries
Other Non-ASEAN Countries
Malaysian Student
Foreign Student
27th Nov 2015 Pre – Conference Workshop Limited places for workshops. Register early to avoid disappointment.
28th & 29th Nov 2015 Conference
Early Bird
before 31st Aug 2015
Post Early Bird between 1st Sept to 14th Nov 2015
Onsite 15th Nov 2015 to during conference
Terms and Conditions
If your membership detail is not filled in or is no longer current, your registration will automatically be processed as a Non-MASM Member.
If you wish to check your status, please contact MASM secretary (Mr.Udesh) at 017 686 1168 or sportsmed.my@gmail.com
If you are a Malaysian Student, please attach a letter from your University Dean or Head of Faculty on University letterhead.
If you are a Foreign Student, please attach proof from your University Dean or Head of Faculty on University letterhead.
TOTAL AMOUNT DUE
D. PAYMENT MODE
Please Select Payment Mode
Attach Proof
[ max file size : 20MB ]
Please attach scanned document of either bank-in cash, bank-in cheque or online transfer slip or telegraphic transfer slip.
*Please make sure the name of the attachment does not contain special characters.
Attach Student Proof
[ max file size : 20MB ]
All payments are to be issued in favour of "Malaysian Association of Sports Medicine "
Bank
CIMB Berhad
Account No
8007412959
Bank Address
27, Jalan 52/2, Bandar Baru Petaling Jaya, 46050 Petaling Jaya, Selangor
Bank Branch Telephone
03-79553806
Swift Code
CIBBMYKL
CANCELLATION AND REFUND POLICY
The secretariat must be notified in writing of all cancellations. Refund will be made only after the conference and only applicable under following circumstances:
Cancellation on or before 30th September 2015 : 95% refund
Cancellation after 1st October 2015 :No refund.
If no refund is required but a change in participant registration is needed, then the Secretariat must be informed in writing via email to secretariat@malaysiansportsmed.org
CONFERENCE SECRETARIAT
MALAYSIAN ASSOCIATION of SPORTS MEDICINE
c/o BLOOM COMMUNICATIONS
P1-2-1, Andalucia, Pantai Hill Park,
Jalan Pantai Permai, Bangsar South,
59200 Kuala Lumpur, Malaysia.
Tel: +603 2242 0902 /+6016 335 0036
Email: secretariat@malaysiansportsmed.org
Website : www.malaysiansportsmed.org
Fax: +603 6207 6795