V JAKARTA 2012 I. PERSONAL INFORMATION
FULL NAME (as per passport, underline SURNAME) Serial Number:
Network Group Name
IR ID# Name of AVP/VC/
Country
Name of V-Leader Nationality
Mobile No.
E-Mail II. PAYMENT INFORMATION VCON Jakarta 2012 REGISTRATION RATE
Please tick √
USD 300 or MYR 910 or INR 13,600 or PHP 13,100
E-CARD # :
Pin Code:
Amount:
Amount:
Amount:
refer to Note #2
Pin Code:
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Pin Code:
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E-VOUCHER #:
Amount:
E-CARD # :
Pin Code:
Pin Code:
E-VOUCHER #:
E-CARD # :
Pin Code:
ECARD
E-VOUCHER #:
E-CARD # :
Pin Code:
CPV
E-VOUCHER #:
E-CARD # :
Pin Code:
CASH
Pin Code:
refer to Note #2
E-VOUCHER #:
Amount:
Pin Code:
refer to Note #2
Terms and Conditions: (Disclaimer attached behind) 1) Registration is on first come first served basis and is open to all IR's 2) PLEASE PROVIDE US WITH VALID CPV AND AUTHORISATION LETTER IF USING THIRD PARTY CPV (WE WILL NOT BE ABLE TO PROCESS EXPIRED CPV) 3) The Registration fee is NON-REFUNDABLE and non-transferable and will serve as full payment for VCON Jakarta 2012 only. 4) In case there is an outstanding balance, we have the right to request to deduct from IR's quest account or from commission cheque. 5) Confirmation Letter will be sent to IR when full payment is successfully received by The V 6) I have read and understood the terms and condition as stated above and the disclaimer as stated at the back of these form v-regn@the-v.net Signature
Date E & OE