Download 16th Dubai World Dermatology and Laser

REGISTRATION FORM
16th Dubai World Dermatology and
Laser Conference & Exhibition
12th - 14th April | Dubai International Convention & Exhibition Centre
Email*:
Prefix:
Prof.
Dr.
Mr.
Mrs.
Ms. (Please write name in BLOCK letters)
Note: The name mentioned below will appear the same in the Certificate of Attendance
First Name*:
Last Name*:
Job Title*:
Company*:
Address Line 1*:
City*:
Country*:
Work Phone*:
Fax:
P.O.Box*:
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* Mandatory
Early Bird Registration
UNTIL
December 31, 2015
Pre-Registration
Registration
February 28, 2016
April 1, 2016
p Pre-Conference Course (8-11 April 2016)
- - - - -
AED 3,150
AED 3,350
p Cosmetic Course (11 April 2016)
- - - - -
- - - - -
AED 3,030
AED 2,030
AED 2,220
Select [R] your Registration
Dermatology & Dermatopathology
Skin Fillers & Botox
p Conference (12-14 April 2016)
Entitlements:
AED 1,850 • Attendance Certificate
• Conference or Course Materials
UNTIL
AFTER
• Verification of Participation (Credit Points)
• Lunch and Coffee Break
Together we support research
By registering, you are supporting “Al Jalila Foundation for Medical Education & Research Support”
NOTE: • The participants should understand that the speakers provide only their perspective of any new techniques and procedures; and potential risks might be possible if
it is applied into clinical practice without sufficient education, training and /or supervision.
• If VISA is required, kindly send the Visa Application Form and a Valid Passport Copy along the registration confirmation. Form can be downloaded from
www.index.ae/visa.
PAYMENT can be made either by cash or credit card to: INDEX® Conferences & Exhibitions Organisation Est.
PAYMENT DETAILS
q Cash q Visa q Master Card
Credit Card No.
Expiry Date
MONTH
YEAR
Name on Card_________________________________________________________________________________________________
AUTHORIZATION NOTE
Please debit my credit card with an amount of AED........................ I, ...............................................................................................the
card holder will honor this transaction and not hold INDEX® Conferences & Exhibitions Organisation Est. responsible if the
credit card number has been compromised.
CANCELLATION POLICY
I understand that the above mentioned charges per registration will be non-refundable.
Date: _________ /_________ / ____________
Signature:______________________________
For Registration, contact: Tel: +971 4 3624717 | Fax: +971 4 3624718 | [email protected]