ACCOMMODATION FORM

KONGRES NASIONAL (KONAS) PABI V

PENGEMBANGAN PROFESI BEDAH BERKELANJUTAN (P2B2) PABI XV
PARTICIPANT (Kindly Completed)

Title :  Prof  Dr  dr  Specialist  Other

Full Name :

Organization/Institution :

Mailing Address :

Country :

Zip Code :

Mobile Phone :

Email :

Sponsor : Name:

Mobile Phone :

Please Mark (√) on Hotel you choose

HOTEL TYPE IDR/NIGHT/NET HOTEL TYPE IDR/NIGHT/NET

 Superior  IDR 1.100.000  Superior  IDR 1.000.000

 Aryaduta
 Deluxe  IDR 1.200.000  Deluxe  IDR 1.200.000
 Novotel
 Junior Suite  IDR 2.000.000  Happiness  IDR 850.000
 Maxone
 Family Suite  IDR 2.500.000  Warmth  IDR 1.100.000

 Arista  Deluxe  IDR 1.400.000  Horison Ultima  Deluxe  IDR 1.000.000

 The Excelton  Deluxe  IDR 1.100.000  Amaris  Smart  IDR 500.000

 Aston  Deluxe  IDR 1.300.000  Fave  Standard  IDR 850.000

 Grand Zuri  Superior  IDR 900.000

 The 101  Superior  IDR 800.000
 Santika  Superior  IDR 700.000

CHECK - IN DATE: CHECK - OUT DATE: TOTAL NIGHT (S):

TOTAL IDR

* Cancellation of Registration and Refund

 Hotel room rate is net including 2 (two) breakfast

 Please note that official check in time is 15.00 local time and check out time is 12.00 local time

 Approval of early check-in and late check-out is at discretion of the hotel

 Cancellation not later than January 1st, 2018, the refund is 75%. February 1st, 2018 the refund is 50%. Beyond the specified time, there is no refund

 For hotel services not included in the package, will be charged via personal account when check-out by the hotel

 For all travel agents, sponsor or personal MUST reserve the accommodation through the committee (this is to avoid "double reservation")

PAYMENT BY SIGNATURE
Bank Name : Bank Mandiri Branch Palembang RSMH
Acc. No : 112 00 1282 3865
Acc. Name : PANITIA KONAS V PIT PABI XV PALEMBANG
Swift Code : BMRIIDJA

THIS FORM TOGETHER WITH THE REQUISITEMENT PAYMENT AND/OR DOCUMENTATION SHOULD BE EMAILED/FAXED TO:
The Congress Secretariat at GPD Indonesia: Phone: +62217254424, +62217229339, +628111332664 | Fax: +6221 – 7396261
Email : erlin@gpdindonesia.com | konas2018.pabi@gmail.com