ADVANCE REGISTRATION FORM Early Bird Registration Deadline: 13 October 2014 INTERNATIONAL PETROLEUM TECHNOLOGY CONFERENCE Kuala Lumpur Convention Centre, 10-12 December 2014, Kuala Lumpur, Malaysia All portions of this form must be completed. Print your name as they should appear on meeting badge. Registration would not be processed without payment. PARTICIPANT PROFILE Registrant’s First Name (Forename) Spouse’s/Partner’s First Name (if attending) Company Last Name (Family Name) Spouse’s/Partner’s Last Name Job Title or Position P.O. Box or Street Address City State/ Province Country Zip/Postal Code Office Telephone (Include country/city code) E-mail Address Mobile (Include country/city code) Facsimile (Include country/city code) Emergency Contact Telephone (Include country/city code) Emergency Contact Name Membership, please check all that apply:  AAPG  EAGE  SEG  SPE Membership #________________________ Endorsing Organisations:  ASEG  EFG  GPA  GSA  GSL  GSM  HKIE  IADC  IEM  IGU  ISQEM  MGA  MOGSC  NZIGE  OGP  QGS  SEAPEX  WSO Technical Discipline, please check all that apply:  Petroleum Engineering  Geosciences  Other #___________________________ Technical Sessions (Please indicate relevant technical sessions of your interest)  Development & Production  Drilling & Completions  Facilities  Geosciences  Integrated Reservoir  Mid-Stream Gas  Over-Arching Themes  Reservoir Engineering  Unconventional Panel and Plenary Sessions (Please indicate relevant panel and plenary sessions of your interest)  Panel Session 1: Are we Delivering Fit for Purpose Oil & Gas Field Developments?  Panel Session 2: How to Deliver HSSE and Operational Excellence?  Panel Session 3: How do we make Unconventional to Conventional?  Panel Session 4: Collaboration, Outsourcing or Building Internal Capabilities? Lessons Learnt!  CEO Plenary Session: Innovation and Collaboration: Keys to Affordable Energy  Executive Plenary Session: State of the Industry: Game Changing Technologies  Technology Leaders Plenary Session: Leveraging Technology – Current Challenges & Opportunities for the Future FEE PER PERSON QTY COST REGISTER EARLY AND SAVE By 13 October US$995 US$1,095 US$900 After 13 October US$1,095 US$1,195 US$1,000 Complimentary Comp. REGISTRATION Full conference period include technical sessions, exhibition, coffee breaks, daily luncheons, conference dinner, poster session reception and one (1) copy of the Conference Proceedings.  I will attend the Conference Dinner on Wed, 10 Dec  Yes  No  I will attend the Conference Dinner with Spouse/Partner  Yes  No Member Nonmember Presenter/Author/Panelist/Committee/Session Chair Student - With valid college ID only (Includes technical sessions, exhibition and coffee breaks) ONE DAY REGISTRATION US$400 US$500 Member US$500 US$600 Nonmember Complimentary Visitors (Exhibits Only) Indicate Day  Wed  Thu  Fri Includes technical sessions, exhibition, coffee breaks and daily luncheon for the day you have selected. Indicate Day  Wed  Thu  Fri ADDITIONAL TICKETS AND CONFERENCE PROCEEDINGS US$55 US$200 US$200 US$300 Young Professionals Workshop for Full Conference Delegates Only - TOTAL US$ REGISTRATION/ ENQUIRIES ONLINE FAX MAIL TEL E-MAIL http://www.iptcnet.org/2014/kl/ (Credit Card Registration Only) +65.6290.5887 (If faxed, do NOT mail original) International Petroleum Technology Conference, Limited c/o SPE-Asia Pacific (M) Sdn Bhd. Level 35, The Gardens South Tower Mid Valley City, Lingkaran Syed Putra 59200 Kuala Lumpur, Malaysia - Daily Luncheon tickets Indicate Day(s)  Wed  Thu  FRI Conference Dinner Additional Conference Proceedings – Member Additional Conference Proceedings – Nonmember This is a limited attendance workshop. Registration will be accepted on a first-come first-served basis. Please tick box if you wish to attend. (Tuesday, 9 December 2014)  YES! I would like to attend. Cancellation Policy:  Cancellation received by 13 October 2014 will be refunded less US$150 processing fee.  Cancellation received after 13 October 2014 will be refunded less US$150 or 25% of registration fee whichever is greater.  Cancellation after 24 November 2014 is not eligible for a refund.  No refund if delegate fails to attend. PAYMENT OPTIONS  Telegraphic Transfer (Bank details will be provided on the invoice)  American Express  Master Card  Diners Club  Visa Card Number Expiry Date (mm/yy) CVV Code CVV code is the 3 digit code on back of VISA/ MasterCard and the 4 digit code on the front of American Express Name as it appears on card ZIP/Postal Code of card Billing address of card Signature +65.6297.9322 [email protected] Note:If the registrant is a member of one of the following IPTC Sponsoring or Endorsing Organisations, please provide us their membership number in order to receive the discounted member registration rate. Below are the organisations list that qualify for the Member rate. Sponsoring Organisations 1 American Association of Petroleum Geologists (AAPG) 2 European Association of Geoscientists & Engineers (EAGE) 3 Society of Exploration Geophysicists (SEG) 4 Society of Petroleum Engineers (SPE) Endorsing Organisations 1 Australian Society of Exploration Geophysicists (ASEG) 2 European Federation of Geologists (EFG) 3 Gas Processors Association (GPA) 4 Geological Society of America (GSA) 5 Geological Society of London (GSL) 6 Geological Society of Malaysia (GSM) 7 Hong Kong Institution of Engineers (HKIE) 8 International Association of Drilling Contractors (IADC) 9 Institution of Engineers Malaysia (IEM) 10 International Gas Union (IGU) 11 International Safety Quality Environment Management Association (ISQEM) 12 Malaysian Gas Association (MGA) 13 Malaysian Oil & Gas Services Council (MOGSC) 14 New Zealand Institution of Gas Engineers (NZIGE) 15 International Association of Oil & Gas Producers (OGP) 16 Qatar Geological Society (QGS) 17 South East Asia Petroleum Exploration Society (SEAPEX) 18 World Safety Organisation (WSO)