PASMAP 13TH ANNUAL CONVENTION live @ zoom November 30 & DECEMBER 01, 2020 Registration Form MEMBERSHIP STATUS * — Select — MEMBER = Php. 1,500 NON MEMBER = Php. 2,000 FOREIGNER = $100 USD OLD MEMBER / RENEWAL FEE = 4000 Name * First Middle Last PRC License Number * Your 7 Digit PRC Number. Duplicate enrollments using the same PRC number are not allowed. PRC License Expiration * Email Address * Mobile Number * Your primary mobile number where you are reachable. We may contact you for verification. Birth Date * Clinic Address * Mode of Payment * Bank Transfer/Deposit - BDO Credit Card/PayPal Payment details will be displayed after registration Already registered but not yet paid? Proceed to Payment