Bali Ophthalmology Retreat 2010

Please fill in the form below for inquiries.

Seats at the preferential Early Bird rate are limited. Please fill in the priority registration form and submit it back ASAP!

* 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
Registration Fee per delegate seat for the three-days Bali Ophthalmology Retreat (BIOR) on Friday, April 30 to Sunday, May 2, 2010:

Early Bird Rate (on or before March 18, 2010) USD 200** / IDR 1,500,000*
Regular Rate (March 19 to April 22, 2010) USD 250** / IDR 2,000,000*
Late Registration (April 23, 2010 onwards) USD 300** / IDR 2,500,000*

Delegate fees include access to all sessions, scheduled lunches and refreshment breaks IDR rates are for Indonesia Residents Only

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)

HOTEL/TRAVEL INFORMATION

Official Venue Hotel :

AYANA Resort & Spa Bali
Jl. Karang Mas Sejahtera, Jimbaran, Bali 80364
Phone: 62-361-702222 Fax: 62-361 701555
Website: http://www.ayanaresort.com

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

Please book me a room at:

1. AYANA Resort & Spa Bali (number of available rooms: 12)
1-Bedroom Ocean View Villa, USD 521 Net/night
1-Bedroom Ocean View Suite, USD 277 Net/night
Guest Room, USD 183 Net/night

2. Keraton Jimbaran (number of available rooms: 9)
Deluxe, USD 115 Net/night
Superior, USD 100 Net/night

3. Sari Segara (number of available rooms: 2)
Standard, USD 57 Net/night

4. None of Above
None, USD 0 Net/night

Number of Rooms

Check in date :

Check out date:

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

(Exchange rate at 10 Mar 2010 : 1 USD = IDR 9,400)

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, 2010.

TERMS AND CONDITIONS

All conference registrations are made subject to the following terms and conditions of BIOR 2010 as set out below:

Deadline:

To qualify for the Early Bird registration discount, your registration form and payment must be received by Wednesday, March 17, 2010. Otherwise the regular rate will be changed.
To qualify for Regular rate, your registration form and payment must be received by Thursday, April 22, 2010. 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: + 62 811 134134, + 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