Bali Ophthalmology Retreat 2010

Please fill in the Registration information below and submit back ASAP with the required applicable information.

Take note that seats are strictly limited and that you should urgently act to avail of the preferential Early Bird Rate while still available.

* Title: (Mr./Ms./Dr.)
* First name:		* Last name:
*Position:		Clinic/Hospital:
* Correspondence Address:
* Country:		* City/State:
Zip Code:		* Mobile:
Phone (ex: 62215646688):		Fax:
* Email:
* Name exactly to be written on Certificate:

* Enter Securty Code above:
	NOTE: Items marked with () are required fields*

PAYMENT INFORMATION
BIOR 2011 will be held Friday, May 20 - Sunday, May 22, 2011.

Registration Fees for the three-day event follow:

Early Bird Rate (on or before March 14, 2011) USD 225** / IDR 1,800,000*
Regular Rate (March 14 to May 12, 2011) USD 300** / IDR 2,500,000*
Late Registration (May 13, 2010 onwards) USD 350** / IDR 3,000,000*

Delegate fees include access to all sessions, scheduled lunches and refreshment breaks.
All sessions and functions will be held at the Bali Conrad

Accompanying Person (optional)
Yes, I would like to register an accompanying person and pay an additional USD 150 ** / IDR 1.300.000 *
(includes scheduled lunches and refreshment breaks)
To also attend the Welcome Dinner, please add an additional USD 60** / IDR 500,000*

*IDR rates are for Indonesia Residents Only
**USD rates are for Overseas Delegates

HOTEL INFORMATION
Special rates have been contracted at the following official BIOR hotels for delegates. Rooms are limited, so please book early.

Official Venue Hotel :

Conrad Bali
Jl. Pratama 168 Tanjung Benoa, Nusa Dua, Bali 80363
Phone: 62-361-778788

Please book me a room at:

1. Conrad Bali
Deluxe Room, USD 225 Net/night

2. Grand Mirage Resort & Thalasso Spa Bali
Deluxe Ocean View, USD 122 Net/night
Deluxe Garden, USD 105 Net/night
Extra Bed, USD 45 Net/night

3. Aston Bali Resort & Spa
Ocean View Suite, USD 155 Net/night
Deluxe Ocean, USD 111 Net/night
Deluxe Room, USD 100 Net/night
Extra Bed, USD 50 Net/night
Ocean Front Suite, USD 188 Net/night

4. None
I will arrange my own accommodation

Number of Rooms

Check in date :

Check out date:

(Exchange rate at 04 Sep 2010 : 1 USD = IDR 0)

Methods of Payment
Note: Seats are confirmed only upon receipt of full payment

	Credit Card Use nsiapay payment gateway. After this, you will be redirected to a very secure page (provided by nsiapay) for filling out your credit card information. We would not save / store your credit card information. Note: For Overseas Delegate credit card payments, the US Dollar amount total is reflected in Indonesian Rupiah in the Payment Order based on the prevailing exchange rate at time of transaction.

	Bank Transfer (in Indonesian Rupiah / IDR) Account name: PT. Austindo Nusantara Jaya HealthCare Account number: 085-01-00706-00-8 Swift Code: CHAS US 33 a/c no 544-723151 Name of Bank: PT. Bank Niaga Address: Jl. Jend. Sudirman Kav.58-Jakarta (via JP Morgan Chase Bank, New York)

	Bank Transfer (in US Dollar/ USD) Account name: PT. Austindo Nusantara Jaya HealthCare Account number: 085-02-00369-00-7 Swift Code: CHAS US 33 a/c no 544-723151 Name of Bank: PT. Bank Niaga Address: Jl. Jend. Sudirman Kav.58-Jakarta (via JP Morgan Chase Bank, New York)

Important:
Your hotel room can ONLY be confirmed upon sending your credit card details as a guarantee. Hotel bills are to be settled by delegates directly with the respective hotel. Travel arrangements are the sole responsibility of the registrant. If the delegate wishes to cancel reservation, a one-day stay shall be charged upon notice. Please make your hotel reservation and payment at least two (2) months prior to the event. Room rates are subject to change without prior notice due to high season of Golden week of April, 2011.

TERMS AND CONDITIONS

All conference registrations are made subject to the following terms and conditions of BIOR 2011 as set out below:

Deadline:

To qualify for the Early Bird registration discount, your registration form and payment must be received by Monday, March 14, 2011. Otherwise the regular rate will be changed.
To qualify for Regular rate, your registration form and payment must be received by Thursday, May 12, 2011. Otherwise the late registration rate will be charged.

Cancellation : If you have settled the payment with respect to point no. 1 and you can't attend the event, the payment will not refundable, but you can send a substitute.

No Deductions and Withholdings : The rates quoted are NET amount to be remitted with no deductions and withholdings for taxes or others purposes.

CONTACT DETAILS

BIOR Secretariat
Klinik Mata Nusantara, Jl. Arjuna Utara 50, Kebon Jeruk, Jakarta 11510, Indonesia

Ms. Rini at Tel: + 62 812 13662929, + 62 21 564 6688 ext 515, Fax + 62 21 564 2072
or Email: Esti.Hastarini@klinikmatanusantara.com
Ms. Aby at +62 811 995687, Fax + 62 21 526 1416 or Email: pfebiana@austindo.co.id