REGISTRATION FORM DELEGATE INFORMATION TITLE: FIRST NAME: LAST NAME: ID/PASSPORT NO: NATIONALITY: ORGANIZATION NAME: ORGANIZATION ADDRESS: CITY: STATE: POSTAL CODE: EMAIL: MOBILE NUMBER: EMERGENCY CONTACT NUMBER/NAME: DIETARY REQUIRMENTS DIETARY No Dietary Requirement Vegetarian Vegan Peanut Allergy * All foods served in the hotel are halal SECTION 1 :: REGISTRATION FEE If Other, Please Specify (Dietary) A. MAIN CONGRESS REGISTRATION 7 th 8 th October 2016 Berjaya Times Square Hotel, Kuala Lumpur. CATEGORY SUPER EARLY BIRD (25 Dec 2015 15 Feb 2016) EARLY BIRD (16 Feb 31 Mar 2016) NORMAL REGISTRATION (1 Apr 31 Aug 2016) LATE REGISTRATION (1 Sept 30 Sept 2016) Local MPA Member 1,050 1,150 1,250 1,350 Local Non MPA Member 1,750 1,950 2,150 2,350 Local Student 950 1,000 1,050 1,100 Local Retiree 950 1,000 1,050 1,100 Local Day Registration 900 980 1,080 1,200 Local Accompany Person 850 950 1,050 1,250 MPA Member YES NO MPA Membership Number: I. All fees are inclusive of 6% GST. II. All registration categories except Accompany Person category have the access to all plenary and concurrent sessions. III. All registration categories are entitled to receive the congress material, access to exhibition & poster area, refreshment breaks and lunches. IV. Only Accompany Person category can enjoy free accompany tour during the congress day. (Tour Name To Be Advise) V. Fees for gala dinner, accommodation, flights, and airport transfers are NOT included in the congress registration fees. VI. Student rate only applies to all 'Undergraduate' students in any universities. A copy of Student ID card or Letter from University is required for verification. VII. Post Graduate student are required to register as normal delegate. VIII. Retiree rate applies to all Malaysian retirees only. A copy of Retirement Card is required for verification. IX. Payment for Malaysian Delegate should be made in (Malaysian Ringgit) only. X. 10% discount will be accorded to Group Registration with a minimum of 10 delegates. Kindly request the Group Registration Form from the Secretariat via email at secretariat@acpt2016kul.org. *Terms & Conditions Apply Page 1
B. PRE-CONGRESS WORKSHOP 5 th 6 th October 2016, 9AM - 5PM WORKSHOPS REGISTRATION FEE Motor Control Training for Low Back and Pelvic Pain by Paul Hodges 1,600 Articular Manual Therapy for Mechanical Neck Pain Disorders by Vaidas Stalioraitis 1,500 Treatment of Cerebral Palsy with Bobath Techniques by Hong Jung Sun 1,000 McConnell Approach to the Problem Knee by Alfio Albasini MRY 1,500 C. POST-CONGRESS WORKSHOP 9 th 10 th October 2016, 9AM - 5PM WORKSHOPS REGISTRATION FEE McConnell Approach to the Problem Shoulder by Alfio Albasini 1,500 Note: Venue to be advised. II. Registration fee is inclusive of refreshment breaks and lunches. SECTION 2 :: GALA DINNER & OPENING CEREMONY You are cordially invited to the MPA partly subsidised Gala Dinner with minimal entrance ticket as append below: NUMBER ITEM RATE/PAX OF PAX Gala Dinner (Delegate) 200 N/A Registered Accompany Person 200 N/A Additional Ticket(s) 300 Total II. Gala Dinner ticket is only entitled for one person only. SECTION 3 :: AIRPORT TRANSFER Flight details are required for airport transfers. These details must be received not later than 1 st September 2016. (Kindly email us your date/time of arrival/departure and flight number to secretariat@acpt2016kul.org if you have not provided the details upon submitting registration form). Flight Details: ARRIVAL DETAILS Pick Up Point KLIA KLIA2 Drop Off Point Arrival Date Arrival Time (HH:MM) Carrier Name Flight No. Flight Details: DEPARTURE Pick Up Point DETAILS Drop Off Point KLIA KLIA2 Departure Date Departure Time (HH:MM) Carrier Name Flight No. AIRPORT TRANSFER By CAR Maximum 2 passengers only One Way Transfer One Way Transfer With Midnight Surcharge By VAN Maximum 4 passengers only One Way Transfer Airport to City Hotel 170 255 250 375 One Way Transfer With Midnight Surcharge NUMBER OF PAX City Hotel to Airport 170 255 250 375 TOTAL * KLIA = Kuala Lumpur International Airport * KLIA2 = Kuala Lumpur International Airport 2 AIRPORT TRANSFER AMENDMENTS AND CANCELLATION POLICY: II. All transfers are on private basis. III. All amendments must be made in writing fourteen (14) days prior to the transfer booked date. IV. No refund for cancellation made after 15 th September 2016 for transfers booked and paid. V. No refund will be granted for no-show reservations. VI. Pick up for departure airport transfer is 4 hours prior to the flight ETD. Passenger(s) is(are) advised to be punctual to avoid disappointment. VII. One CAR is for a maximum of two passengers only. VIII. One VAN is for a maximum of four passengers only. Page 2
Midnight Surcharge applies for the following: I. Arrivals: Flight ETA between 23:00hrs and 07:00hrs. II. Departures: Flight ETD between 01:00hrs and 09:00hrs SECTION 4 :: ACCOMMODATION HOTEL NAME Berjaya Times Square Hotel Kuala Lumpur Furama Hotel Kuala Lumpur Royale Bintang Hotel Kuala Lumpur HOTEL RANKING 5-Stars TYPE OF ROOM RATES / NIGHT BREAKFAST NUMBER OF ROOM (S) Studio Single 430.00 Studio Double 465.00 4-Stars Superior 270.00 4-Stars Ansa Kuala Lumpur 4-Stars Deluxe 295.00 Superior 315.00 Deluxe 325.00 Complimentary Starbucks Voucher TOTAL () Check In Date : (DD/MM/YYYY) Check Out Date : (DD/MM/YYYY) Name of 2 nd Guest : (if applicable) Term & Conditions: II. Room rates are nett price. All rooms are subject to availability and individual hotel policy applies. III. Payment for accommodation must only be made via Credit Card. IV. For inquiries, please send e-mail to us at secretariat@acpt2016kul.org. SECTION 5 :: SPONSORED & DAILY TOURS A. CONGRESS SPONSORED TOURS TOUR DATE TIME (hrs) A. Kuala Lumpur City Orientation Tour 9 Oct 2016 0830 1230 B. Kuala Lumpur Countryside Tour 9 Oct 2016 0830 1230 C. Cheras Rehabilitation Hospital 9 Oct 2016 0830 1230 Terms & Conditions: I. The above tours are sponsored by ACPT 2016. II. Seats are limited. Kindly confirm your attendance by 31 st August 2016 in order to confirm your seat. Failure to do so, your seat will be open to other delegates. III. Pick-up & drop-off points will be at the Berjaya Times Square Hotel, Kuala Lumpur. B. DAILY TOURS TOUR A. MUD, STORY OF KUALA LUMPUR TIME (hrs) PRICE PER PAX PRICE FOR TWO (2) PAX 1400 1800 335 395 B. PUTRAJAYA SIGHTSEEING 0830 1230 480 535 C. KUALA LUMPUR BY NIGHT 1700 2200 385 495 REMARKS Inclusive of MUD Show Entrance Ticket Inclusive of Putrajaya Cruise Inclusive of Dinner and Cultural Performance D. MALACCA DAY TRIP 0900 1700 690 770 Inclusive of Lunch E. KUALA SELANGOR FIREFLIES TOUR F. SUNWAY LAGOON THEME PARK 1600 2200 755 825 0930 1530 730 910 Inclusive Seafood Dinner and Entrance Ticket Inclusive of All Park Entrance Total G. A DAY IN RAINFOREST 0900 1500 295 Minimum of 4pax Date of Tour 4 th Oct 2016 5 th Oct 2016 Name of 2 nd Pax: (if applicable) Name of 4 th Pax: (if applicable) Name of 3 rd Pax: (if applicable) Page 3
Term & Conditions: II. All tours are on private basis based on maximum of 2pax, except for A Day in Rainforest which is based on minimum of 4pax. III. Kindly visit our website at www.acpt2016kul.org for more information about the tours. IV. Pick-up & drop-off points will be at the Berjaya Times Square Hotel, Kuala Lumpur. V. All amendments must be made in writing fourteen (14) days prior to the tour booked. VI. No refund for cancellation made after 15 th September 2016 for tours booked. VII. No refund will be granted for no-show reservations. All the passengers are advice to be punctual. SECTION 6 :: SUMMARY PAYMENT DETAILS Section 1: Registration Section 2: Gala Dinner Section 3: Airport Transfer Section 4: Accommodation Section 5: Sponsored & Daily Tours TOTAL () SECTION 7 :: PAYMENT METHOD ( ) 1. CREDIT CARD ( ) 3% Admin Fees Applicable I hereby authorize ACPT 2016 AOSCE to charge my credit card for the total amount of Cardholder Name: Card Number: - - - Secure Code (CVV/CVC): Expiry Date: / (MM/YY) Card Type: MasterCard Visa Signature: * Note: Please attach a scanned copy of your credit card upon your submission of this form for verification purpose. 2. TELEGRAPHIC / BANK TRANSFER ( ) Payment via transfer must be made without charges to beneficiary and payable to: Account Name : ACPT 2016 AOSCE Account Number : 3121 9453 5566 Bank Name : Standard Chartered Bank Malaysia Berhad Bank Address : KL Main Branch, Ground Floor, No. 36 Jalan Sultan Ismail, 50250 Kuala Lumpur, Malaysia Swift Code : SCBLM-YK-XXXX 3. LOCAL PURCHASE ORDER ( ) LO Number: Amount: SECTION 8 :: TERMS AND CONDITIONS OF REGISTRATION I. Registration Entitlement 1. All fees are inclusive of 6% GST. 2. All registered participants (except Accompany Person category) may enjoy the all access to the congress sessions 3. All registered participants are entitled for opening ceremony, coffee/tea breaks, lunches, access to the exhibition and poster area, delegate bag and other related congress materials. 4. Only Accompany Person category can enjoy free accompany tour during the congress day. (Tour Name To Be Advise) 5. Student rate only applies to all 'Undergraduate' students in any universities. A copy of Student ID card or Letter from University should be sent to the ACPT 2016 Secretariat via e-mail at secretariat@acpt2016kul.org or fax to +603 4257 1133. 6. Post Graduate student are required to register as normal delegate. 7. Fees for gala dinner, accommodation, flights, and airport transfers are NOT included in the congress registration fees. II. Registration Process and Payment 1. Participants may register via online registration at www.acpt2016kul.org. Alternatively, they may complete the registration form and send it to the ACPT Secretariat via e-mail at secretariat@acpt2016kul.org or fax to +603 4257 1133. 2. Online registration is only open until 30 th September 2016 (GMT +8hrs). After 30 th September 2016, kindly register onsite at the congress venue where registration counter will be open on 6 Oct 2016 from 2pm 5.30pm. 3. Full payment of registration fee must be received by 31 st August 2016 (accept payment via Local Order). 4. For payment made via Local Order (LO), the original copy of LO must be received by 31 st August 2016. Please mail the original copy of the LO (Local Order) to the ACPT 2016 Secretariat for verification purpose. 5. Confirmation letter of registration will be sent via email upon full payment of the registration fee received. Please bring along the confirmation letter and present it at the registration counter during the congress. 6. Payment of registration fees can be made via: a. Credit Card (Visa & MasterCard only. 3% admin fee is required.) b. Telegraphic Transfer c. Local Order (Applicable to Malaysian Government Agencies only) d. Bank Cheque (Applicable to Malaysia s Local Bank Cheque only) Page 4
7. For payments made by Credit Card, the amount reflected in the Credit Card statement will be in the currency of the cardholder's country of origin. If an invoice is requested, the amount paid will be reflected in only. 8. The Organiser reserves the right, and will inform Participants on any alteration to any of the arrangements for the ACPT 2016 including the cancellation of the event should unforeseen circumstances require such action. 9. In the special circumstances that the entire event has to be cancelled, the Organiser will refund the registration fee to the Participants. However, the Organiser will not be liable for other associated costs, e.g. accommodation and travelling expenses, and any inconveniences incurred to the Participants due to the cancellation. Therefore, Participants are advised to arrange for their own travel insurance. III. Registration Transfer All registrations are transferrable on or before 30 th September 2016. Transfer requests must be made by e-mail to the ACPT 2016 Secretariat at secretariat@acpt2016kul.org or fax to +603 4257 1133. The new Participant should complete the registration form and revert to us by 30 th September 2016. Transfer of registration will not be allowed on or after 1 st October 2016. IV. Cancellation and Refund Policies 1. All cancellation of registration must be done in writing and submitted to the ACPT 2016 Secretariat via e-mail at secretariat@acpt2016kul.org or fax to +603 4257 1133. 2. Any cancellation on or before 31 st July 2016 will be entitled for 75% refund from the total Paid Registration Fee. 3. Any cancellation within 1 st August 2016 until 31 st August 2016 will be entitled for 50% refund from the total Paid Registration Fee. 4. Refund will be made after deducting other related fees and charges incurred in connection with such refunds, including costs of foreign exchange conversion, Credit Card cancellation and/or banking transaction. 5. Any cancellations on or after 1 st September 2016 will not be refunded. 6. All refunds will be made in at the prevailing foreign exchange rate. 7. Refund for cancellations will be made within three months after the congress. Any charges imposed by banks and Credit Card issuers will be borne by the Registrants. VI. Liability The Organiser reserves the right to make changes where deemed necessary, with or without prior notice to parties concerned. All disputes are subjected to the Malaysian Law. We kindly ask you to authorise us by your signature to use all registration data given in this form for computerised handling of the conference. I hereby accept all terms of participation without reservation or restriction and we relinquish any claims against the Organiser. The Organiser reserves the right to cancel or postpone the Conference due to unforeseen circumstances. Signature: Date: (By signing and returning this form, you are accepting all the terms and conditions) ENQUIRIES For enquiries, please contact us at: secretariat@acpt2016kul.org Please return this form to: ACPT 2016 Congress Secretariat c/o AOS Conventions & Events Sdn. Bhd. (Member of AOS Tourism & Hospitality Group) Address: 2 nd Floor No. 39 & 40, Jalan Mamanda 9, Ampang Point, 68000 Selangor, Malaysia. Office Number: +603 4252 9100 Fax Number: +603 4257 1133 Email: secretariat@acpt2016kul.org Website: www.acpt2016kul.org Hosted By: Supported By: Official Airlines Partner: Page 5