REGISTRATION FEE:

Translating Theory into Practice Early (until Feb 28, 2019)

MDs, Nurses
Health Care Practitioners
REGISTRATION FORM P4, 000

Students, Residents, Fellows

2ND PATIENT SAFETY CONGRESS P3, 000
28-29 MARCH 2019
PHILIPPINE INTERNATIONAL CONVENTION CENTER (PICC) Regular (after Feb 28, 2019)
PASAY CITY
MDs, Nurses
Health Care Practitioners
Please complete this registration form and send it via e-mail or P 5, 000
fax. If you prefer to send the form by postal mail or fax, please
contact: Students, Residents, Fellows
P 4, 000

2ND PS Congress Secretariat (The conference fee is inclusive of

Office of the Postgraduate Institute of Medicine materials, meals and certificate)
547 Pedro Gil Street, Ermita Manila
All cheques shall be made payable to:
1000 Philippines
TeleFax No: 536-1319 Account Name:
E-mail: patientsafetyph@gmail.com UP Medical Alumni Foundation
(UPMAF), Inc. - (for check payment
Participant’s Information: the complete account name should be
indicated in the check)
 Professional Title: (i.e. Dr., RN., RPh., etc) _____________ Account No. :
 First Name: _______________________________________ 3283-5519-29 _ Peso Savings Account

 Middle Initial: ____________________________________ Bank/Branch: BPI - Ermita Branch

 Last Name: _______________________________________ Address: Midland Plaza Condominium

M. Adriatico Street Manila
 Ext Name: (i.e. Jr., II etc.) ___________________________
For payment made thru Bank of the
 Position: _________________________________________ Philippine Islands (BPI) kindly email
 Affiliation: (Company or Organization) or fax a copy of the deposit slip at the
number and email address above.
_________________________________________________ Personal and Manager’s check are not
accepted.
 Mobile number: ___________________________________
Deadline of registration and payment
 Email Address: ____________________________________ for early rate is on Feb 28, 2019 only
and for regular rate is on Feb 29,
 Please check: (Convention Symposia) 2019 onwards.
□ Executive Development Track
□ Clinical Track For further questions please contact the
□ Innovative Track Congress Secretariat.

Payment approved by: ___________

Amount: ___________
OR No.: ___________
Date: ___________
Cashier: Ms. Karen T. /Ms. Marie Z.