Registration Form PIDD 2012

First Name:
Last Name:
Designation:
Title: Other : (please state)
Affliliation:
Address:
Phone:
E-mail:
Payment : Enclosed is my payment of RM to be made through:
(tick x appopriate box)
 Online Payment :
Please proceed : http://epayment.upsi.edu.my/
 Banker's Cheque
Cheque Number : Cheque Issuing Bank :
 Local Order (For Malaysian Only) LO Number :
 Money Order MO Number :
Payable to BENDAHARI UPSI.
For further queries,Contact
Phone:+Fax:+
Email:Website : http://www.pidd2012.com



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