Group  Code:
（Association Name）		 Password：
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The person in charge of the group (Group Leader) should send an e-mail to tao.taiwan@msa.hinet.net with his/her full address and contact details and the group leader will be provided with a login and password。

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*Title: Professortrans Drtrans Mrtrans Mrstrans Ms
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*Last Name: *First Name:
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*Mailing Address:
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Zip/Postal code: *Country:
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Fax: *E-mail:

How many persons:
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Title: Professortrans Drtrans Mrtrans Mrstrans Ms
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Last Name: First Name:
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Title: Professortrans Drtrans Mrtrans Mrstrans Ms
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Last Name: First Name:

Dentist: NTD10,000（USD 300）
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Dental student: NTD4,000（USD 120）
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Accompanying person: [NTD1,500（USD 50）for each person]

I certify that: is a full time dental student.
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Name of Institution:
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Name of the Director:
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Email address
of the Director:

Golf tournament – 10th Dec 2010: ticket(s) x NTD3,400（USD 95）
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Gala dinner – 11th Dec 2010: ticket(s) x NTD1,500（USD 50）

attend not attend
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Please order lunch box(s) x NTD300（USD 10）

Airport to Taipei Hotel person x NTD 640 (USD 20)
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Taipei Hotel to Airport person x NTD 640 (USD 20)
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Arrival Departure airport:
Flight No: Date: 12/9 12/10
Time: : Hotel:
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Departure Flight No:    
Date: 12/12 12/13 12/14
  Time: :
Note:
Please click here to contact us, if your arrival flight cannot match with above time period

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*Name of Cardholder:
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Total payment NTD
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SENS

WIOC 2010 Taiwan Association of Orthodontists