ADMIN ONLINE REGISTRATION – Joint Annual Convention

ONLINE Registration

(August 1 to September 30, 2016)

Early Bird: August 1 to September 5, 2016
Vouchers: August 1 to September 12, 2016
Advance: September 19 to September 26, 2016

Please ensure that you internet connection is stable prior to submitting your registration

* Required Fields

First Name *

Middle Initial

Last Name *

Suffix

Professional Suffix *

Sex

Birthdate *
(MM/DD/YYYY)

Category *

Please specify category: *

Requirements to avail Discounted Rate what’s this?
(NOTE: required for inductee, trainees, rad. tech., students, and allied professional to avail the discounted rate, Accepted file types: jpg,png; Size: less than 5MB)

Institution/Hospital Affiliation *

Mobile Number * (NOTE: required to fill up at least one (1) network)

Globe/TM Number

Sun Number

Smart/TNT Number

Email Address *

PRC License Number *(Note: If not applicable, please input 000)

PRC License Expiration *(Note: If not applicable, please input 01/11/2011)
(MM/DD/YYYY)

PMA Number (NOTE: must be filled up to avail CME units)

Bank *

Branch Code *what’s this?

Reference/Confirmation Number *what’s this?

Date of Payment *Sample
(MM/DD/YYYY)

Amount Paid *

Payment Proof
* (NOTE: Full name must be written on deposit slip. Accepted File Types: jpg, png, Size: less than 5MB)

– If Group Payment Deposit Slip, indicate total amount deposited:

– Official Receipt to be issued to:
(NOTE: if left blank, Official Receipt will be automatically issued under the registrant name specified above)

Remarks