Registration: 20th Annual Asean Course in Head and Neck surgery Registration: 20th Annual Asean Course in Head and Neck Surgery(29th - 31st January 2024) Title * Select TitleMr.Mrs.Ms. First Name *Please enter your first name This name-last name you provide on the form will appear on the certificate. Last Name *Please enter your last name (as you would like to be addressed) Position * SelectResidentFellowStaff Specialty * SelectENTPlastic surgeryMaxillofacialOther Specialty Hospital/ Affiliation * Country * Email address * Dietary restrictions * None Vegan Halal Register fee * Lecture 100 USD (สำหรับคนไทย 3,000 บาท) Lecture +Workshop Ultrasound 200 USD (สำหรับคนไทย 6,000 บาท) Lecture +Workshop Microvascular anastomosis 200 USD (สำหรับคนไทย 6,000 บาท) Lecture +Workshop Cadaver 1000 USD (สำหรับคนไทย 30,000 บาท) Need a receipt for government reimbursement * Yes No Payment *Please transfer the above amount of the course fee to our account. Bank name: The Siam Commercial Bank Branch: Rajavithi Hospital Account no: 0512734200 Account name: Center of Excellence in Otolaryngology, Rajavithi Hospital Swift code: SICOTHBK Transaction date. * Transaction Time. * 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM Total Amount Transferred: * Account Name. * Please attach proof of payment. * Drop a file here or click to upload Choose File Maximum file size: 50MB (a file extension PDF. or JPG. only) You can receive a special price from the Abloom Exclusive Serviced Apartments ( 150 m near BTS Sanam Pao )Please contact the email provided before booking. Email: Sales_manager@abloombangkok.com Tel: +6622723010 Submit Clear If you are human, leave this field blank.
