Registration Form August, 2017 Kuala Lumpur Convention Centre, MALAYSIA A. DELEGATE DETAILS. Prof Assoc. Prof Dr Mr Mrs Ms.

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1 A. DELEGATE DETAILS Prof Assoc. Prof Dr Mr Mrs Ms First Name: Last Name (Surname): Job Title: Organisation: Organisation Address: Postal Code: Country: Tel (Office): Mobile: Fax: DIETARY REQUIREMENTS Dietary Requirement: No Dietary Requirement Vegetarian Others If Others, please specify: 1 of 6

2 B. REGISTRATION FEES Registration Type Early Registration Normal Registration Onsite Registration (on or before 17 th July 2017) (18 th July 7 th August 2017) (After 8 th August 2017) International Doctor USD 500 USD 600 USD 650 Paramedics / Nurses / Pharmacists/ Allied Health USD 480 USD 580 USD 630 **With Online Multimedia Presentation USD 120 USD 150 USD 180 Local Doctor MYR 1,800 MYR 2,200 MYR 2,400 Paramedics / Nurses / Pharmacists/ Allied Health MYR 1,600 MYR 2,000 MYR 2,200 **With Online Multimedia Presentation MYR 480 MYR 600 MYR 720 Industry MYR 1,800 MYR 2,200 MYR 2,400 Pre-Congress International Delegate USD 180 USD 220 USD 260 Local Doctor MYR 600 MYR 720 MYR 840 Local Paramedics / Nurses / Pharmacists/ Allied Health MYR 480 MYR 600 MYR 720 Gala Dinner on 22 nd August 2017 USD 90 / MYR 360 Accompanying Person USD 150 / MYR 600 IMPORTANT NOTES: All of the fees mentioned above are subject to the 6% Goods and Services Tax. For all categories of registration, the Secretariat will charge the appropriate full rate if the delegate fails to provide the necessary information or proof. Registration will only be confirmed electronically by upon receipt of FULL PAYMENT. The Registration fees include admission to all sessions, coffee breaks, lunches, Welcome Reception on 20 th August 2017 but not the conference dinner, optional tours, airport transfer and accommodation. The Accompanying Persons fee include admission to Welcome Reception, and the Gala Dinner. Tours, airport transfer and accommodation are optional. Acceptance of registration is at the sole discretion of the Organiser. Confirmation of registration will be sent in writing upon receipt of full payment. ** Online Multimedia Presentations We will PARTIALLY record the plenary, symposium and workshop sessions for post-congress viewing online. Add this package to your registration to review presentation in a state-of-the-art format that includes streaming audio and video, and synchronized slides. Make this purchase when registering for the congress online and Save significantly over postcongress purchase of individual plenary sessions. 2 of 6

3 C. PRE-CONGRESS WORKSHOP AND WORKSHOP (Please tick appropriate box to reserve seat on your preferred session.) 20 th August 2017 (Sunday) Physician Track Physician Track (Simultaneous Hands On Sessions) Physician Track (Cardio Renal Symposium) Nurses Track Nurses Track Nurse Track (Simultaneous Hands On Sessions) MSN Symposium 1 NRR Highlights and Future Directions MSN Symposium 2 Viewpoints MSN Symposium 3 Updates 21 st August 17 (Monday) & 22 nd August 2017 (Tuesday) 21 st August (Please pick one ONLY) Workshop A CRRT Technique 1 AKI CRRT Concurrent Workshops Session 1 Workshop B Critical Care Nephrology 1 Workshop C Hemodynamic and Fluid Management 1 Workshop D Dialysis Technique and Plasma Exchange MSN Symposium 4 AKI in Special Situations 21 st August (Please pick one ONLY) Workshop A CRRT Technique 2 AKI CRRT Concurrent Workshops Session 2 Workshop B Critical Care Nephrology 2 Workshop C Hemodynamic and Fluid Management 2 Workshop D Peritoneal Dialysis for AKI MSN Symposium 5 Dialysis Technique 22 nd August (Please pick one ONLY) Workshop A CRRT Technique 3 AKI CRRT Concurrent Workshops Session 3 Workshop B Critical Care Nephrology 3 Workshop C Hemodynamic and Fluid Management 3 Workshop D Biomarkers in AKI MSN Symposium 6 Dialysis Access 3 of 6

4 D. TERMS AND CONDITIONS Payment for Malaysians will be in MYR and in USD for everyone else. International delegates can make payment by Credit Card and Telegraphic Transfer. Malaysians can make payment by Local Cheque, Credit Card, Telegraphic Transfer or Local Order. Please note that all related bank charges, financial charges or credit card administrative fees of 5% (subject to 6% GST) are to be borne by the delegates and are not to be deducted from the net fee payable to the congress. Official invoice and receipt will be provided only upon request. Company Cheque (for Malaysians Only) and Telegraphic Transfer are to be made to the congress bank account below: Account Name : AKI CRRT 2017 KL Account Number : Account Bank : Malayan Banking Bhd Bank Address : Wisma Genting Branch, Jalan Sultan Ismail, Kuala Lumpur, Malaysia. SWIFT Code : MBBEMYKL CONFIRMATION Registration will only be confirmed upon receipt of FULL PAYMENT. An confirming the registration will be sent upon receipt of full payment. Please bring along the confirmation and present it at the Registration Counter when collecting your delegate badge on the congress day (actual time and date will be informed in due course by ). CANCELLATION All cancellation of registration must be done in writing and submitted to the Congress Secretariat by at registration@ apcrrt2017.com.my.» Cancellation received on or before 3 rd July 2017: 100% refund. (Deduct an administration fees of USD 100)» Cancellation received after 3 rd July 2017: no refund. Paid registration fee is not refundable after the stipulated date for whatever reasons including failure of obtaining VISA. All refunds will be made in MYR at the prevailing foreign exchange rate. Refund for cancellation will be made within three months after the congress. 4 of 6

5 E. PAYMENT DETAILS Enclosed in my total payment of MYR / USD Company Cheque (for Malaysians Only) Cheque No: to be made through (tick appropriate box) Cheque Issuing Bank: *Important Note: Kindly make Cheque/Bank draft payable to AKI CRRT 2017 KL. Telegraphic Transfer T.T Reference No: T.T From (Bank Name): *Important Note: Please scan your TT slip and to the Congress Secretariat for verification Local Order (for Malaysians Only) Local Order Reference No: Credit Card I authorise MCI Management Malaysia Sdn Bhd to debit the total amount of MYR/USD from my credit card account (details provided below) for the Registration fee. This transaction will appear as MolPay*MMMSB-MCImanagement on your credit/debit card billing statement. Type of Card: MasterCard Visa Card No: Exp. Date (MM/YY): Name on Card: Card Holder Signature: Secure Code: (CVV/CVC) Date: 5 of 6

6 E. LIABILITY The Organiser reserves the right to make changes where deemed necessary, with or without prior notice to parties concerned. All disputes are subject to the Malaysian Law. We ask you to kindly authorise us, by your signature, to use all registration data given in this form for computerised handling of the Congress. * Signature: Date: *By signing and returning this form, you are accepting our terms and conditions * Please return this form to: 1st Asia Pacific AKI CRRT 2017 Congress Secretariat C/O MCI Management Malaysia Sdn Bhd ( W) Suite 12-9, Level 12, Wisma UOA II, Jalan Pinang, Kuala Lumpur, Malaysia T: F: E: registration@apcrrt2017.com.my 6 of 6