MIND SCIENCE CONGRESS II REGISTRATION FORM*

MSM Membership No. …………………... Date of Expiry : ………… (For MSM members only)

PERSONAL PARTICULARS

Name : ……………………………………….. ………………………………………..	Sex : M/F
Address :
…………………………………………………..
……………………………………………………………..
……………………………………………………………..
Mobile Ph. : ……………	Email : ………………………
Fixed Line Ph. ………………(O/H)	Fax ………………….
Nationality : …………… …………………...	Occupation :

I confirm that I wish to be registered as a participant for “MIND SCIENCE CONGRESS II” and the above particulars are correct.

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Signature

REGISTRATION FEE payable (Please tick)

EARLY BIRD RM200.00 each_______

GROUP OF FOUR RM230.00 each_______

GROUP OF TEN RM210.00 each ________

INDIVIDUAL RM250.00 each ________

WALK-IN RM250.00 each ________

All Registration Forms should be accompanied with FULL PAYMENT or BANK-IN SLIP.

The cheque(s) should be made in favour of : “MIND SCIENCE CONGRESS”

For Bank-in deposit your cheques into :-MAYBANK A/C NO. 514141-334435 MBB Branch, 3^rd mile, Jln. Ipoh KL