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HACKAWAY

Engineered by:

WORKSHOP REGISTRATION FORM


MAIL or FAX to:
NOTE: All portions of this form must be completed. Registration will not be processed without payment.
This form can be used as a company invoice. Registration
Condition Zebra
Registrants Full Name (Same as per IC / Passport) Level 2 - 11, Block F,
Phileo Damansara 1,
A h m a d Z a f i r J a f f a r Jalan 16/11, Off Jalan Damansara,
46350 Petaling Jaya,
Selangor Darul Ehsan,
Title or Position MALAYSIA.
Tel: (60) 3 7665 2911
T e c h n i c a l M a n a g e r
Fax: (60) 3 7665 2011
(If you fax this form, do NOT mail original)

Company / Organisation
T h e t a E d g e B e r h a d Please visit
www.inforisk-360.com
for further information on
P.O. Box or Street Address Condition Zebra event and training
B a n g u n a n C P e r e m b a S q u a r e
S e c t i o n U 2 PAYMENT OPTIONS:
City State Malaysia Ringgit Cheque or Demand Draft
Payable to Condition Zebra (M) Sdn. Bhd.
S h a h A l a m S e l a n g o r
Electronic Transfer in Malaysia Ringgit to:
Country Zip / Postal Code
Condition Zebra (M) Sdn. Bhd.
Bank details will be provided on the invoice.
M a l a y s i a 4 0 1 5 0
MasterCard
Mobile Number Office Telephone
Visa
0 1 6 2 3 3 6 5 6 7 (Credit Card Payment will be in
Malaysia Ringgit only.)
E-mail Address
REFUND DEADLINE: Cancellations must be
d z a f i r @ t h e t a - e d g e . c o m submitted to this office and postmarked 3 working
days before the workshop.

Note: 1. For credit card payment, 3% extra will be


levied for administrative processing fee.
Registration Fees 2. Cash & Credit Card Payment will be in
Malaysia Ringgit only.
Workshop RM QTY TOTAL
Name as it appears on Card

Billing address of Card

* Terms and conditions apply. TOTAL

Confirmation Details Card Number


After received payment, a receipt and notification email will be issued. If you have any queries regarding this, please contact
Condition Zebra at (60) 3 7665 2911. All payment must be received 3 working days before the date of Workshop!

Note: Minimum charge of RM499 will be charged to participant who fails to turn up for the workshop after confirmation of attendance. Security Code

Authorisation
Signatory must be authorized to sign on behalf of contracting organization. Exp. Date

Name: Signature

Cancellation Policy

Cancellation or refunds must be notified in writing.


Position: Cancellation MUST be made 3 working days before
the date of the workshop. The organizers reserve the
right to make any changes to the event.

Signature:
All information contained herein is correct at time of printing
Company Stamp (Oct 2014) and is subject to changes without prior notice.

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