Download Registration Form
Please return this form to secretariat office at:
WONCA 2006 Secretariat Office:The Royal College of Family Physicians of Thailand11th Floor, Royal Golden Jubilee Building,2 Soi Soonvijai, New Petchaburi Road,BANGKOK, THAILAND 10320
Tel. 662 716 6651-3 Fax. 662 716 6653
Website: www.wonca2006.org

Registration Form


Please type or write in block letters
Delegate *: Prof. checked> Dr. checked> Mr. checked> Mrs. checked> Miss. checked>
First name *:    
Middle name *:  
Last name * :    
Institution:
Address * :
City *:    
State : Zip * :
Country:  
E-mail *:  
Phone: Fax:

Name of Accompanying Person:  
Given
Middle
Family
Given
Middle
Family


I.Registration Fees

 
Early before June 30, 2006
Late June 30 -
October 15, 2006
Onsite After
October 15, 2006
WONCA Member
US$ 300
US$ 350
US$ 400
Regular Participan
US$ 350
US$ 400
US$ 450
Student and Trainee *
US$ 100
US$ 120
US$ 150
Accompanying Person          US$ 120
US$
Cultural Night (November 7) US$ 60
US$
Total Fee (US$):
Total Payment (US$):

Mode of Payment

 
Credit card


VISA Master card JCB
Bank Transfer

Bank transfer made payable to "WONCA 2006".
Account name:WONCA 2006
Account number:
Bank name: SIAM COMMERCIAL BANK PUBLIC COMPANY LIMITED
Address:
Swift Code: SICOTHBK
Note: Please fax and/or mail proof of payment to
Tel. 662 716 6651-3 Fax. 662 716 6653

Credit Card Holder :

 Please type or write in block letters
Delegate: Prof. checked> Dr. checked> Mr. checked> Mrs. checked> Miss. checked>

First name : Last name :
Address
E-mail:
**PAYMENT INFORMATION ================
Payment status :Send your Email:
Subject: SIPS Transaction Response
From: sipsadm@scb.co.th