66th COE of IOA - OTS Form
Banjarmasin, May 9-12th 2018
Name
Mr.
Mrs.
Miss.
dr.
Prefix
First Name
Middle Name
Last Name
Name for Certificate
*
Please write your name correctly for certificate
Email Address
*
Status of Participation
Orthopedic Surgeon
Resident of Orthopedic
General Practitioner
Overseas Delegate
Workshop Participation
Yes
No
Hotel Reservation
*
Yes
No
Room Type
Golden Tulip Galaxy Hotel - Superior Room - IDR 1,250,000 / USD 180
Golden Tulip Galaxy Hotel - Deluxe Room - IDR 1,500,000 / USD 210
Golden Tulip Galaxy Hotel - Grand Deluxe Room - IDR 1,800,000 / USD 260
Mercure - Superior Room - IDR 1,150,000 / USD 170
Mercure - Deluxe Room - IDR 1,300,000 / USD 200
Mercure - Deluxe Executive Room - IDR 1,600,000 / USD 250
Check-In Date
8-5-2018
9-5-2018
10-5-2018
11-5-2018
Check-Out Date
9-5-2018
10-5-2018
11-5-2018
12-5-2018
13-5-2018
Total Night (s)
Your check-in or/and check-out Date is invalid. Please change it!
Total Accommodation Price
Total Registration Price
Total (Accomodation + Registration)
Grand Total to Pay
Payment Method
Cash
Debit or Credit Card
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*
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