ACPJ Viral Diseases and Leptospirosis Webinar Registration form

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Sunday, June 14, 2020
Contact us at (876) 898-3763 or acpj-secretariat@outlook.com

Banking information:
NCB Private Banking
124-126 Constant Spring Road
JMD dollar account #291000479
(Business Chequing Account)

*Please send a picture of the transaction or send the transaction details to our email after making your payment

Email *

Can you attend? *

Yes, I'll be there

Sorry, can't make it

Name *

Organization/Association *

Telephone number

Specialty

Parish of work

Registration information *

ACPJ member - $1,500.00

Doctors - $2,000.00

Residents with ID, Nurses and Allied Medical Professionals - $1,500.00

Medical Student with ID - Free

Company Sponsor

Please select the one that best represents you *

I have already paid online

I will pay soon

I will pay on the day of the Webinar

I am a presenter

I am a sponsor

I am a Medical Student

Send me a copy of my responses.

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