On-line Conference Registration

Registration Form

Personal Details of Delegate (Fields marked with * are mandatory)
Full Name *	Mr Ms Mrs Dr Miss    (e.g. Steven Tan)
Family Name/Surname*	(e.g. Tan)
Name to appear on conference badge *
Company *	(e.g. Insurance Company Pte Ltd, XYZ Pte Ltd)
Industry Segment *	InsurerReinsurerInsurance BrokerReinsurance BrokerInsuredRisk ManagerAuditorActuaryRating AgencyConsultantOthers Others (Please specify below)
Job Title / Designation*
Mailing Address *
City/State
Postal Code*
Country *	AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote D'ivoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, metropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea (North)Korea (South)KuwaitKyrgyzstanLaoLatviaLebanonLesothoLiberiaLibya Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and IslandsSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVatican City StateVenezuelaVietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaYemenYugoslaviaZaireZambiaZimbabwe
Telephone *
Fax *
E-mail *
Secretary's E-mail (if any)
Additional Information	Please tick the appropriate checkbox This is my first time attending an SIRC event. I will require a Letter of Invitation from the Organiser for visa application purposes.
Catering Arrangements	I confirm my attendance at: Welcome Cocktail on 30 Oct 2011 Networking Lunch on 31 Oct 2011 Networking Lunch on 1 Nov 2011 The 11th SIRC Organising Committee will cater light breakfast for registered delegates at Melati function room, Level 4, Sands Expo and Convention Center, from 7am to 9am on Oct 31 and Nov 01, 2011. All meals served at the Conference will be prepared without pork and lard. To cater to the special dietary needs of delegates, a separate vegetarian section will be provided and all dishes containing beef will be clearly marked.
Golf Tournament	I will be participating in the Golf Tournament on Wednesday, 2 Nov 2011. Current Golf Handicap: Home Club (if any):
Regular Fee S$1480 per Delegate
Conference Fees	Early Registration Fee (extended till 15 July 2011) S$1,180 Regular Fee (from 16 July 2011) S$1,480 Golf Tournament Fee Per Participant S$220
Total Fees Payable	S$
Mode of Payment	By cheque/draft in Singapore dollars drawn on a Singapore bank and made payable to the "Singapore College of Insurance Limited" By telegraphic transfer (in Singapore Currency) to : Beneficiary: Singapore College of Insurance Limited Bank Account No: 001-053726-1 Name of Bank: DBS Bank Ltd Address of Bank: 6 Shenton Way, DBS Tower 2, Singapore 068809 Swift Code: DBSSSGSG * I will undertake to indemnify the organisers for all bank charges. Credit Card (for VISA or MasterCard only)
Cancellation / Substitution Policy	Any cancellation of registration notified in writing before 30 September 2011 will be allowed subject to payment of an administration fee of S$250. No refunds will be allowed for cancellations notified thereafter. However substitution or replacement of delegates will be allowed.
Please check and print a copy of the completed online Registration Form, if needed, before submission.

Copyright © 2011 Singapore College of Insurance Limited. All Rights Reserved by SCI.