REGISTRATION FORM (SINGLE PASS) APPLIED 4.0: DIGITALIZING EMERGING TECH CONFERENCE Date: 15 – 17 April 2020 Venue: The Majestic Hotel, Kuala Lumpur Designation Name per I/C or Passport Gender Gender Female Male Work/ Personal Email Mobile Number Meal Preference Meal Preference Normal Diet (No restrictions) Vegetarian Other If Other, please mention here. If you are representing a Company, type your Organization name here. If not, leave blank. Where did you learn about this Conference? Where did you learn about this Conference? Brochure Email Newspaper ads Newspaper article Facebook Instagram Word of Mouth Google Search / Website Others Payment Method - Secured Payment Gateway via Billplz (Please tick to proceed) Payment Method - Secured Payment Gateway via Billplz (Please tick to proceed) I understand that payment must be made in full via Billplz. Billplz is a secured payment gateway. Once payment is made, you will receive a proof of payment in your Inbox from them. To complete your registration, please head to https://www.billplz.com/B2SCApplied4150420 to make payment of RM4,000. Back2SchoolCo by Surge Connection Sdn Bhd is an official Marketing Partner for Applied 4.0: Digitalizing Emerging Tech Conference. Proceed to Billplz