JOINT ANNUAL CONVENTION 2021 REGISTRATION

PRC License # (If none, enter 000)

PRC Expiration Date

Category

NOTE: name typed will be followed for the certificate

First Name

Last Name

Suffix

Professional Suffix

(ex. MD, RRT, RMT, RN, etc)

Cell Phone Number

Cell Phone Provider

Email Address

Confirm Email Address

Email addresses do not match.

Hospital or Clinic Affiliation/Practice

Payment Type

Payment Date

Reference/Confirmation Number

Branch Code

Origin Bank Name

Voucher Code

Payment Proof (.jpg or .png)

**Please ensure that your Internet Connection is stable prior to submitting your registration. Click submit button once, processing may take a few seconds or a minute. Thank you

NOTE: Strictly no refund, no change of name nor transfer of registration will be accepted. Please REGISTER correctly. ALL SUBMITTED DATA WILL BE KEPT CONFIDENTIAL AND SECURE. THANK YOU

By clicking the Register button below, I attest that I have read and accepted the Privacy Policy and hereby authorize CTMRISP & USP to collect and process my data indicated herein for the purpose of data collection regarding my registration. Personal information is protected by RA 10173 of the Data Privacy Act of 2012 and will be kept confidential and secure.