The PCCP 38th ANNUAL CHEST CONVENTION

Theme: “Beyond Borders: Advancing Real-World Pulmonology”

March 05-08, 2019  Edsa Shangri-La, Manila, Mandaluyong City

REGISTRATION FORM

DATA PRIVACY CONSENT FORM

I am aware that the information supplied in the form will be retained by the Organizing Committee of the PCCP
38th Annual Chest Convention on a database and will be processed in compliance with the Data Protection Act
of 2012.
I consent that the information herein may be used for reports and documentation purposes.
________________________ __________
Signature over Printed Name Date

DELEGATE Please Type or Print

Last Name: First Name: MI:
Mailing Address:
Designation: PRC # Mobile #
Membership: Tel No. / Fax No. /E-mail Address:

CATEGORY:
 PCCP Member  Non-member Delegate  Government Physician  Fellow-in-Training
 Resident  Intern  Respiratory Therapist  Medical Technologist  Nurse

REGISTRATION FEES
 Check if you are disabled and require Registration will be processed only when
assistance (attach a written description of needs) accompanied by total payment. Reproduce forms for
additional registration. Entire form must be submitted.

PRE-REGISTRATION RATE APPLIES on or before Feb. 8, 2019 (Friday)

POST-GRAD COURSE ANNUAL CONVENTION ANNUAL CONVENTION

March 15, 2019 + POST-GRAD COURSE PROPER
CATEGORY (Day 0) March 5-8, 2019 March 6-8, 2019
(Day 0-3) (Day 1-3)
PRE-REG ON-SITE PRE-REG ON-SITE PRE-REG ON-SITE
 Member Php2,000 Php2,500 Php3,500 Php4,500 PhP2,500 PhP3,000
 Non-Member Php2,500 Php3,000 Php4,500 Php5,500 PhP3,000 PhP3,500
 Gov’t. Physicians Php2,000 Php2,500 Php3,500 Php4,500 Php2,500 Php3,000
 Fellows-in-Training/
Resident / Intern / Php1,500 Php2,000 PhP2,500 PhP3,500 Php2,000 Php2,500
Paramedical
 Foreign Delegates USD $200 USD $250 USD $450 USD $500 USD $300 USD $350

PAYMENT PROCEDURE:
Check payment should be made payable to THE PHILIPPINE COLLEGE OF CHEST PHYSICIANS, INC.
Return this form and payment to 38th ANNUAL CHEST CONVENTION
Philippine College of Chest Physicians Convention Secretariat
You can also deposit the payment at Metropolitan Bank & Trust Company (METROBANK)
Acct. Name: THE PHILIPPINE COLLEGE OF CHEST PHYSICIANS, INC. / Current Acct. No. 007-232-52482-7

❖ Kindly fax this form together with the deposit slip @ 924-0144 or e-mail at andrea.santiago@philchest.org /
andrea2011@hotmail.ph

For inquiries contact: PCCP Secretariat - Telephone Number: (632) 924-9204; Telefax Number: (632) 924-0144
E-mail Address: secretariat@philchest.org and andrea.santiago@philchest.org / andrea2011@hotmail.ph

Room 4015, 4/F Lung Center of the Philippines, Quezon Avenue,, Quezon City PHILIPPINES 1100
 (632) 924-9204, 924-6101 Loc. 4105  Fax No. (632) 924-0144
E-mail address: secretariat@philchest.org and pulmonologist@philchest.org Website address: www.philchest.org