MPS JOHOR RETRO NIGHT
REGISTRATION FORM
Title *
Name *
Pharmacist Registration Number *
Workplace *
Email Address *
Telephone Number *
Are you a MPS member? *
How many ticket would you like to purchase?
Would you be able to attend the event? *
Are you a vegetarian? *
Would you be interested to perform on stage? *
Do you have any comment and/or question?
Thank you very much!
Please proceed with the payment within 5 days after the submission of this registration form.
Online bank transfer can be made to: MPS-Johor Area Committee, Account Number: 011300010179717, Alliance Bank.
Please email the proof of payment to mpsjohorretronight2019@gmail.com

Thank you for registering with us. A confirmation email will be sent to your email address provided upon confirmation of payment. We look forward to seeing on 23 Nov!
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