MALAYSIAN PALM OIL BOARD

Conference Registration Form
International Seminar on 100 Years of Technological Advancement in Oil Palm Breeding & Seed Production

13 NOVEMBER 2017
Location:  KLCC, Kuala Lumpur, Malaysia
Name *
Salutation
Organisation *
Are you a Malaysian? * Yes No
Malaysian IC No. *
Industry Sector *
If OTHERS, please specify :
E-mail *
Alternative E-mail*
(e.g.: @yahoo, @gmail, @hotmail)
Designation
Address
City
Postcode
State
Country
Telephone
Faxsimile
Special Dietary Request (Vegetarian) Yes No
Participant Status ISOPB Member Non-Member
Payment Instructions Payment by cheque/Local Order will be sent to MPOB
Please charge the following card (see instruction below)
Will pay at the counter by cheque/credit card (MasterCard/Visa)
Credit Card Instruction
Please print out the Registration Form and sign on the Cardholder signature box, enclose photocopy of credit card and provide credit card information as follows:
Name as printed on card
Credit Card Number
Type of Card Mastercard Visa
Expiry Date
Cardholder Signature_