PPAIFI 12th Annual Convention

PPAIFI 12th Annual Convention
Name to Appear in Certificate *

First NameMiddle NameLast Name
Email*
example@example.com
Mobile Number*
(917) 123-4567

Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NOTE: For Trainees without clinic, please put Address of Training Institution
Clinic Mobile Number*
(917) 123-4567

PRC ID No.*
Expiration Date*

MonthDayYear
Date
Upload PRC ID*

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PMA Number*
Specialization*
Affiliation*
Please Specify Society / Training Institution here for non PPAIFI
Are you a Board Member / Officer of your Society?*

YesNo
If yes, what is your position*
Ex: PPAIFI Vice President (put N/A if not applicable)
Are you an Invited / Sponsored Lecturer?*

YesNo

Registration Options*
prevnext( X )
Member - Two Days Convention
8,500.00PHP



Non-Member - Two Days Convention
9,500.00PHP



Resident / Trainee - Two Days Convention
7,500.00PHP



Biostimulator Workshop PLUS Two Days Convention
30,000.00PHP



Total

0.00PHP
PAYMENT DETAILS

PS BANK

Account Name: PAN PACIFIC AESTHETIC INSTITUTE FOUNDATION INC.

Account Number: 152332000474
Upload Deposit Slip*

Please put name on deposit slip
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