A) Delegate Details

Title: * Prof     Dr     Mr     Mrs     Ms    
Given Name: *
Surname: *
Affiliated Organisation / Institution: *
Address: *
 
State: *
Postal Code: *
Country: *
Phone: *
Mobile:
Fax: *
E-mail: *
Are you vegetarian? *  No   Yes Special dietary requirement (if any):
 

B) Accompanying Person Details (if applicable)

Title: * Prof     Dr     Mr     Mrs     Ms    
Given Name: *
Surname: *
Are you vegetarian? *  No   Yes Special dietary requirement (if any):
 

C) Flight Details (For administration purpose only)

Arrial Date:   Time:   Flight Number:  
Departure Date:   Time:   Flight Number:  
 

D) Registration Fees
Delegate Description Early Registration
(On and before
15th June 2012)		 Normal Registration
(After 15th June 2012 and
Before 1st September 2012)		 Late Registration
(After 1st September 2012)
Regular member
RM 2,790
(USD 900)
RM 3,100
(USD 1,000)
RM 3,720
(USD 1,200)
Associate member
RM 3,720
(USD 1,200)
RM 4,185
(USD 1,350)
RM 4,960
(USD1,600)
Observer
RM 4,650
(USD 1,500)
RM 5,270
(USD 1,700)
RM 6,045
(USD 1,950)
Accompanying Person
RM 1,860
(USD 600)
RM 2,015
(USD 650)
RM 2,170
(USD 700)
a. The Congress registration fees for the delegate include admission to all sessions and the cost of all Congress meals and social events but not optional tours, airport transfers (besides what the Organisers will provide based on the Congress' scheduled airport transfer arrangements) and accommodation.
b. The fees for accompany persons include invitations to the Welcome Reception, Opening Ceremony, 26th EAIC Congress Dinner and Closing Ceremony. The fees do not include any access to any other Congress sessions, optional tours, airport transfers (besides what the Organisers will provide based on the Congress' scheduled airport transfer arrangements) and accommodation.
c. Acceptance of Registration is at the sole discretion of the Organising Committee. Confirmation of Registration will be notified in writing upon receipt of full payment.
d. The RM/USD conversion rate is FIXED at RM3.10=USD1.00 for the Congress and is not subject to any current rate that may differ.
 
 

E) Social Event
Please RSVP the events that you would like to attend by putting a “X” in the appropriate boxes.
Events Delegates Accompanying Persons
Welcome Reception (29th October 2012, 1800 - 2000) Yes, will attend Yes, will attend
Opening Ceremony (30th October 2012, 0900 -1030) Yes, will attend Yes, will attend
26th EAIC Congress Dinner & Closing Ceremony
(1st November 2012, 1900 - 2200)		 Yes, will attend Yes, will attend
 

F) Payment Details
My total payment of RM to be made through:

Master or Visa card:
I would authorised Persatuan Insurans Am Malaysia (General Insurance Association of Malaysia) to debit the total amount of RM  from my credit card for the settlement of the above mentioned fees.
Credit card payment system is under upgrading process.
You will be informed in due course to make your payment again.

AMEX card:
I would authorised Persatuan Insurans Am Malaysia (General Insurance Association of Malaysia) to debit the total amount of RM   from my credit card for the settlement of the above mentioned fees.
Credit card payment system is under upgrading process.
You will be informed in due course to make your payment again.
Company cheque ( for Malaysians only )
Cheque Number:
Cheque Issuing Bank:
Date of Transaction:
*Important Note: Kindly made cheque/bank draft payable to the 26th EAIC 2012
Local Order ( for Malaysians only )
Local Order Reference No :
Telegraphic Transfer ( T.T. )
T.T. Reference No:
T.T. Bank:
Date of Transaction:

Please Telegraphic Transfer (T.T) to the following:
Account Name/ Beneficiary : 26TH EAIC 2012
Account No : 0061-10-003814-6
Bank Name : Hong Leong Bank
Bank Address : Brick­fields Branch
150, Jalan Tun Sambanthan, Kuala Lumpur
SWIFT code : EOBBMYKL

* Please fax the T.T slip to the Secretariat
 

G) Terms and Conditions
 •

Delegate details provided in this Registration Form is limited for the purpose of registration for this Congress only
 •

All payments should be made in RM. International delegates can make payment by Credit Card or Telegraphic Transfer. Malaysian delegates can make payment by Local Cheque, Credit Card or Local Order.
Confirmation
 •

Registration will only be confirmed upon receipt of FULL PAYMENT.
 •

Upon receipt of the FULL Payment, the Congress Secretariat will send you a Confirmation Letter via email.
 •

Please bring along the Confirmation Letter and present it at the time of Registration at the Congress.
Cancellation Policy
 •

Cancellation of registration must be made in writing to the Secretariat. Refunds will only be made after the Congress.
 
- Cancellation received on or before 1st July 2012 : 100% refund (minus an administration fees of RM90.00)
- Cancellation received between 2nd July 2012 and 15th August 2012 : 50% refund
- Cancellation received after 15th August 2012 : No refund
 
* Paid registration fee is not refundable after the stipulated date for whatever reasons including failure of obtaining VISA.

I fully understand and agree to all the terms and conditions
 
   
 
 

Organised and hosted by: Persatuan Insurans Am Malaysia (General Insurance Association of Malaysia)
Congress Secretariat: Console Communications Sdn Bhd
Suite 12.9, Level 12, Wisma UOA II, 21 Jalan Pinang, 50450 Kuala Lumpur, MALAYSIA
Tel: +603 2162 0566 Fax: +603 2161 6560
Email: info@eaic2012kl.com
Website: www.eaic2012kl.com