Bali Ophthalmology Retreat 2012

BALI OPHTHALMOLOGY RETREAT 2012
PRIORITY REGISTRATION FORM

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 2012 will be held on Friday, May 25 to Sunday, May 27, 2012.

Registration Fees for the three-day event follow:

Early Bird Rate (on or before March 15, 2012) USD 300** / IDR 2,500,000*
Regular Rate (March 14 to May 17, 2012) USD 350** / IDR 3,000,000*
Late Registration (May 18, 2012 onwards) USD 400** / IDR 3,500,000*

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

* All sessions and functions will be held at The Conrad
* Rates below are inclusive of breakfast

Please book me a room at:

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

2. Aston Bali Resort & Spa
Deluxe Ocean Room, USD 160 Net/night
Deluxe Room, USD 140 Net/night
Ocean Front Suite, USD 225 Net/night
Ocean View Suite, USD 200 Net/night

3. None
I will arrange my own accommodation

Number of Rooms

Check in date :

Check out date:

(Exchange rate at 06 Feb 2012 : 1 USD = IDR 9,150)

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

	Credit Card Use Doku payment gateway. After this, you will be redirected to a very secure page (provided by Doku) 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:
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

TERMS AND CONDITIONS

All conference registrations are made subject to the following terms and conditions of BIOR 2012 as set out below:

Deadline:

To qualify for the Early Bird registration discount, your registration form and payment must be received by Monday, March 15, 2012. Otherwise the regular rate will be changed.
To qualify for Regular rate, your registration form and payment must be received by Thursday, May 17, 2012. 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 NETT amount to be remitted with no deductions and withholdings for taxes or others purposes.

CONTACT DETAILS

BIOR Secretariat
Klinik Mata Nusantara, Jl. R.A. Kartini No 99, Lebak Bulus 12440 Jakarta, Indonesia

Ms. Rini at Tel: + 62 812 13662929, + 62 21 751 6688 ext 515, Fax + 62 21 751 9344 or Email: Esti.Hastarini@klinikmatanusantara.com
Ms. Anne at +62 8111 256222 Fax + 62 21 526 1416 or Email: anne.yastanti@anj-group.com