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ROAD SAFETY REVIEWER ACCREDITATION COURSE 26 to 29 September 2011 LTA Academy Blk 5A Level 1, No. 1 Hampshire Road, Singapore 219428 Course Fees (SGD) S$2,500 + S$175 (7% Goods & Services Tax, GST) Note: GST is applicable to Singapore based participants only Closing Date for Registration 9 September 2011 Registration Fax or email the completed registration forms to : +65 6396 1585 or [email protected]. Particulars and Experience of Participants Name (use BLOCK letters) : (This name will appear on the Certificate) NRIC / FIN / Passport No : PE Registration No.: Citizenship : Office Tel : Date of Birth : Mobile Tel : Gender: M / F Email : Company Name : Address : Job Designation : Summary of Experience in transport / traffic engineering : I agree that LTA Academy shall not be liable for any loss, damages and/or injury, including loss of life, which I may suffer arising out of or in connection with this Course, whether the loss, damage and/or injury was suffered on any of Land Transport Authority’s premises or at any other venue(s) in connection with this Course. I have read and fully understood all the terms, conditions, requirements and enrolment criteria for this Course. I understand and accept that Land Transport Authority may reject my application for enrolment for this Course at its sole discretion without giving any reason. Signature of Applicant / Date Important: Please proceed to fill in next page for payment purpose. LTA Academy - Course Registration Form Course to register Please register me to attend the following course: Course Title: Road Safety Reviewer Accreditation Course Course Code *: IDM111348 Course Date*: 26 – 29 September 2011 Particulars of participant Name*: Job Title: Department: Organisation*: Country*: Telephone: Number of persons attending: (If more than one, please attach particulars.) Email*: Professional body (Singapore only): Professional registration no.: Contact person for billing purpose (if not the participant) Name: * Telephone: Fax: Email : Mailing address: Department: Payment of course fee by participant Amount of SGD* (S$) : against box)*: I enclose my Cheque/Draft payable to “Land Transport Authority”. Cheque number is: I am paying by bank transfer: copy attached, and the bank draft number is: I am eligible for discount and the amount paid is after discount (see Terms & Conditions) Pay by (please tick Sign and register Authorised signature*: I send signed and completed form, together with payment, by (please tick * ): Mail to LTA Academy, No.1 Hampshire Road, Singapore 219428, Republic of Singapore ………………….......... Date: Fax to (65) 6396 1585 Email to [email protected] (to attach completed form) Method of payment All payment should made in Singapore dollars Payments by S$ bank draft or cheque should be made payable to: “Land Transport Authority”, please quote course title at the back of cheque. Payment by telegraphic transfer, in S$, must be made to: Account Name Account Number Bank and Address SWIFT code LAND TRANSPORT AUTHORITY 001-032012-2 (SGD) Bank Code:7171;Branch Code:001 DBS Bank Ltd 6 Shenton Way, DBS Building Tower 2, Singapore 068809 DBSSSGSG • GST registration number : M4-0006529-2 Enquiries: Mr Sian Chean Chin, [email protected], phone: +65 6396 1570 / +65 9113 3476 or [email protected] Terms and Conditions Withdrawals/Refunds of Fees 1. Notice of withdrawal must be given in writing, policy on refund of course fee is as follows: More than 14 working days before the commencement date : Full refund Less than 14 but more than 7 working days preceding commencement : 50 % refund Within 7 working days before the commencement date : No refund Fee Discount 2. See our programme brochure for eligibility for fee discount or checked with approved the professional organisations in Singapore. LTA Academy reserves the right not to register you if LTA Academy cannot verify your membership with the stated society/organisation or if you do not provide the membership no. 3. You shall pay the remaining amount if LTA Academy is unable to verify your membership with the stated society. Late Interest Payment Charges 4. LTA Academy reserves the right to charge you interest for all late payments. The late interest payment charge shall be at 2% p.a. above the average prevailing prime rate of the local banks as determine by the Authority at the time it is levied. Note: * means input is required.