Title: Prof. Assoc.Prof. Asst.Prof. Dr. Mr. Mrs. Ms. Other

REGISTRATION FORM

I. Identification Title:  Prof.  Assoc.Prof.  Asst.Prof.  Dr.  Mr.  Mrs.  Ms.  Other

First Name Middle Name Last Name Department Institute Mailing Address Country Tel Mobile Fax Email

Special dietary:  Vegetarian  Muslim  Other: please specify:

II. Registration fee Special rate Regular rate Onsite rate Type Now – Nov 15 Nov 16 - Dec 15 Dec 16- Onsite Pre-congress: Cadaveric Workshop (on Dec 16)  THB 21,000 or  THB 22,500 or  THB 24,000 or +  USD 600  USD 645  USD 685 Main Congress (on Dec 17-18) Main Congress only  THB 7,000 or  THB 8,500 or  THB 10,000 or (on Dec 17-18)  USD 200  USD 245  USD 285 Gala Dinner (on Dec 17)  THB 1,750 or  USD 50 *Pre-congress workshop will be arranged at December 16, 2016 at the SiTEC, Siriraj Hospital, seating by first come first served basis only 40 seats (28 International delegate + 12 Thai delegate). *All bank transfer charges must be covered by the sender. *Registered delegates are entitled the admission to all Scientific Sessions and Exhibition, Lunch & Coffee Breaks, and Congress Materials.

III. Payment Online payment by credit card (VISA Card and Master Card) is preferred and the bank transfer/wire transfer would be offered for group registration only. In case of you cannot pay online, registration fee must be transfer to the account below. Account name: IOPBS2016 Account number: 901-7-03976-0 Bank: Bangkok Bank Swift Code: BKKBTHBK Branch: Siriraj Piyamaharajkarun Hospital Bank Address: 2 Wanglang Rd., Siriraj, Bangkok Noi, Bangkok 10700, Thailand Tel: 66-2411-4988, 66-2411-4989, 66-2411-4990 Fax: 66-2411-3662

IV. Cancellations/Refund a) Any cancellation of registration must be made in writing to Conference Secretariat. b) Schedule of refunds: By November 15, 2016: Refund with 30% deduction for administrative fees and will be processed after the congress. No refunds will be accepted from November 16, 2016 onward.