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WAITING LIST REGISTRATION

English Name*:

Chinese Name:

E-mail*:

Contact No.*:

Gender*:

NRIC/Passport:

Religion*:

Correspondence Address*:

City*:

Postcode:

Country*:

State*:

Emergency Contact Name*:

Emergency Contact Phone No.*:

Emergency Contact Relationship*:

Are you a member of Tzu Chi International Medical Association (TIMA)*? Yes No

Profession*:

Doctor

Dental Surgeon

Nurse

Pharmacist

Allied Health

Traditional Chinese Medicine Practitioner

Traditional & Complimentary Medicine

Healthcare Professional Students graduating in 2017

Need Transalation (English to Chinese)? Yes No

Overnight accommodation (for participants outside Klang Valley) No Need Need

Hotel:

Pacific Regency website
Crystal Crown website

Room Type:

Roommate:

If you have picked a twin room, please ensure your room partner does not opt for accommodation to avoid double charging. Thank you.

Check-in Date:

Check-out Date:

Special Request:

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