Symposium Registration Form
Driving Drug Discovery and Drug Development through Academia, Public and Private Partnership
To be held from November 27 – 29, 2017
At Bhumisiri Mangkhalanusorn Building, Faculty of Medicine, Chulalongkorn University
Email address *
Registration Details (*Required)
Title
First Name *
Your answer
Last Name *
Your answer
Position
Your answer
Affiliation
Your answer
Address *
Your answer
Telephone
Your answer
Fax
Your answer
E-mail *
Your answer
Registration Fees:
(Early Registration with Payment Deadline: 11 November 2017, 24:00 HR)
Early Fee (until 11 November 2017) (2,500 THB)
Standard Fee (from 12 November 2017) (3,000 THB)
Drug Discovery (27-28 November)
Early Fee (until 11 November 2017) (1,200 THB)
Standard Fee (from 12 November 2017) (1,500 THB)
Drug Repurposing (29 November)
Early Fee (until 11 November 2017) (3,000 THB)
Standard Fee (from 12 November 2017) (4,000 THB)
Both Topics (27-29 November)
How to make a payment:
1. Bank Transfer to Krung Thai Bank, Siam Square Branch, Saving account no. 052-0-49695-7,
Account holder name “Chula Unisearch – Drug Discovery Conference 2017”
2. Send your Bank Transfer Slip (either a scan, a photo or a .pdf file) with your registration name written on to e-mail: Ekjitra.r@chula.ac.th or fax: (+66) 2-218-2859 as a proof of payment within 5 days of your online registration.
For issuing receipt of payment, if the payment will be done by your Institution / Company, please fill in the following fields:
Company / Institution Name:
Your answer
Address:
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Tax ID (for Thai):
Your answer
For more information please contact:
Research Cluster, Project Management Division, Chula Unisearch, Chulalongkorn University
254 Chulalongkorn Research Building, 4th Floor, Phayathai Road, Pathumwan, Bangkok 10330
Tel: (+66) 2-218-2880 Ext. 444, Fax: (+66) 2-218-2859,
E-mail: Ekjitra.r@chula.ac.th
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