WESTERN ZONAL CONFERENCE REGISTRATION

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After submitting this form, proceed to payment to complete your registration.
Account Name: Christian Medical and Dental Association.
Account Number: 1015063387
Bank: United Bank for Africa (UBA)
Send evidence of payment to Dr. Mrs. Olabinri - 08036520726.

For accommodation enquiries, call Dr. Samuel Blessed - 07039141840.

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First (Given) name *

Last name *

Phone number *

Gender *

Female

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Chapter *

Please specify if you choose other:

Please select appropriate designation *

Prayer points and expectations:

Please select the preferred type of accommodation.

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