<div class="form-group gcore-form-row" id="form-row-custom"><div class="gcore-input gcore-display-table" id="fin-custom"><h2>Leadership & Management From an Islamic Perspective</h2>
10-11 Oct 2018</div></div><div class="form-group gcore-form-row" id="form-row-companyname"><label for="companyname" class="control-label gcore-label-left">Company Name</label>
<div class="gcore-input gcore-display-table" id="fin-companyname"><input name="companyname" id="companyname" value="" placeholder="" size="40" class="validate[&#039;required&#039;] form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-address"><label for="address" class="control-label gcore-label-left">Address</label>
<div class="gcore-input gcore-display-table" id="fin-address"><textarea name="address" id="address" placeholder="" rows="6" cols="40" class="validate[&#039;required&#039;] form-control A" title="" style="" data-wysiwyg="0" data-load-state="" data-tooltip=""></textarea></div></div><div class="form-group gcore-form-row" id="form-row-contactperson"><label for="contactperson" class="control-label gcore-label-left">Contact Person</label>
<div class="gcore-input gcore-display-table" id="fin-contactperson"><input name="contactperson" id="contactperson" value="" placeholder="" size="40" class="validate[&#039;required&#039;] form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-designation"><label for="designation" class="control-label gcore-label-left">Designation</label>
<div class="gcore-input gcore-display-table" id="fin-designation"><input name="designation" id="designation" value="" placeholder="" size="40" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-phone"><label for="phone" class="control-label gcore-label-left">Phone</label>
<div class="gcore-input gcore-display-table" id="fin-phone"><input name="phone" id="phone" value="" placeholder="" class="validate[&#039;required&#039;,&#039;phone&#039;] form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-fax"><label for="fax" class="control-label gcore-label-left">Fax</label>
<div class="gcore-input gcore-display-table" id="fin-fax"><input name="fax" id="fax" value="" placeholder="" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-email"><label for="email" class="control-label gcore-label-left">Email</label>
<div class="gcore-input gcore-display-table" id="fin-email"><input name="email" id="email" value="" placeholder="" class="validate[&#039;required&#039;,&#039;email&#039;] form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><fieldset class="chronoform-container" id="fee-container-34">
					<legend>Registration Fee</legend><p style="font-size:12pt"><em>Seri Pacific Hotel, Kuala Lumpur</em></p><div class="form-group gcore-form-row" id="form-row-accommodation"><label for="accommodation" class="control-label gcore-label-left">Accommodation</label>
<div class="gcore-input gcore-display-table" id="fin-accommodation"><select name="accommodation" id="accommodation" size="" class="form-control A" title="" style="" data-load-state="" data-tooltip="" onChange="disableItem(this)">
<option value="">Please specify</option>
<option value="Without Accommodation">Without Accommodation</option>
<option value="With Accommodation">With Accommodation</option>
</select></div></div><div id="breakfast" style="margin-left:160px;margin-bottom:20px;font-weight:bold;">Executive Deluxe Room with Breakfast for 2 Night</div><div class="form-group gcore-form-row" id="form-row-withoutaccomm"><label for="withoutaccomm" class="control-label gcore-label-left gcore-label-checkbox">Registration Fee</label>
<div class="gcore-input gcore-display-table" id="fin-withoutaccomm"><div class="gcore-single-column" id="fclmn"><div class="gcore-radio-item" id="fitem"><input name="withoutaccomm" id="withoutaccomm" value="Group Fee (for 5-9 pax) - RM1390 per pax" class="A" title="" style="" data-load-state="" data-tooltip="" type="radio" />
<label class="control-label gcore-label-checkbox" for="withoutaccomm">Group Fee (for 5-9 pax) - RM1390 per pax</label></div>
<div class="gcore-radio-item" id="fitem1"><input name="withoutaccomm" id="withoutaccomm1" value="Group Fee (4 pax) - RM1590 per pax" class="A" title="" style="" data-load-state="" data-tooltip="" type="radio" />
<label class="control-label gcore-label-checkbox" for="withoutaccomm1">Group Fee (4 pax) - RM1590 per pax</label></div>
<div class="gcore-radio-item" id="fitem2"><input name="withoutaccomm" id="withoutaccomm2" value="Early Bird - RM1690 per pax" class="A" title="" style="" data-load-state="" data-tooltip="" type="radio" />
<label class="control-label gcore-label-checkbox" for="withoutaccomm2">Early Bird - RM1690 per pax</label></div>
<div class="gcore-radio-item" id="fitem3"><input name="withoutaccomm" id="withoutaccomm3" value="Regular Fee - RM1790 per pax" class="A" title="" style="" data-load-state="" data-tooltip="" type="radio" />
<label class="control-label gcore-label-checkbox" for="withoutaccomm3">Regular Fee - RM1790 per pax</label></div></div></div></div><div class="form-group gcore-form-row" id="form-row-roompref"><label for="roompref" class="control-label gcore-label-left">Room Preference</label>
<div class="gcore-input gcore-display-table" id="fin-roompref"><select name="roompref" id="roompref" size="" class="form-control A" title="" style="" data-load-state="" data-tooltip="" onChange="disableRoom(this);">
<option value="">Please specify</option>
<option value="Twin Sharing">Twin Sharing</option>
<option value="Single Occupancy">Single Occupancy</option>
</select></div></div><div class="form-group gcore-form-row" id="form-row-twinsharing"><label for="twinsharing" class="control-label gcore-label-left gcore-label-checkbox">Twin Sharing</label>
<div class="gcore-input gcore-display-table" id="fin-twinsharing"><div class="gcore-single-column" id="fclmn1"><div class="gcore-radio-item" id="fitem4"><input name="twinsharing" id="twinsharing" value="Group Fee (for 5-9 pax) - RM1790 per pax" class="A" title="" style="" data-load-state="" data-tooltip="" type="radio" />
<label class="control-label gcore-label-checkbox" for="twinsharing">Group Fee (for 5-9 pax) - RM1790 per pax</label></div>
<div class="gcore-radio-item" id="fitem5"><input name="twinsharing" id="twinsharing1" value="Group Fee (4 pax) - RM1950 per pax" class="A" title="" style="" data-load-state="" data-tooltip="" type="radio" />
<label class="control-label gcore-label-checkbox" for="twinsharing1">Group Fee (4 pax) - RM1950 per pax</label></div>
<div class="gcore-radio-item" id="fitem6"><input name="twinsharing" id="twinsharing2" value="Early Bird - RM2050 per pax" class="A" title="" style="" data-load-state="" data-tooltip="" type="radio" />
<label class="control-label gcore-label-checkbox" for="twinsharing2">Early Bird - RM2050 per pax</label></div>
<div class="gcore-radio-item" id="fitem7"><input name="twinsharing" id="twinsharing3" value="Regular Fee - RM2150 per pax" class="A" title="" style="" data-load-state="" data-tooltip="" type="radio" />
<label class="control-label gcore-label-checkbox" for="twinsharing3">Regular Fee - RM2150 per pax</label></div></div></div></div><div class="form-group gcore-form-row" id="form-row-singleoccu"><label for="singleoccu" class="control-label gcore-label-left gcore-label-checkbox">Single Occupancy</label>
<div class="gcore-input gcore-display-table" id="fin-singleoccu"><div class="gcore-single-column" id="fclmn2"><div class="gcore-radio-item" id="fitem8"><input name="singleoccu" id="singleoccu" value="Group Fee (for 5-9 pax) - RM2050 per pax" class="A" title="" style="" data-load-state="" data-tooltip="" type="radio" />
<label class="control-label gcore-label-checkbox" for="singleoccu">Group Fee (for 5-9 pax) - RM2050 per pax</label></div>
<div class="gcore-radio-item" id="fitem9"><input name="singleoccu" id="singleoccu1" value="Group Fee (4 pax) - RM2250 per pax" class="A" title="" style="" data-load-state="" data-tooltip="" type="radio" />
<label class="control-label gcore-label-checkbox" for="singleoccu1">Group Fee (4 pax) - RM2250 per pax</label></div>
<div class="gcore-radio-item" id="fitem10"><input name="singleoccu" id="singleoccu2" value="Early Bird - RM2350 per pax" class="A" title="" style="" data-load-state="" data-tooltip="" type="radio" />
<label class="control-label gcore-label-checkbox" for="singleoccu2">Early Bird - RM2350 per pax</label></div>
<div class="gcore-radio-item" id="fitem11"><input name="singleoccu" id="singleoccu3" value="Regular Fee - RM2450 per pax" class="A" title="" style="" data-load-state="" data-tooltip="" type="radio" />
<label class="control-label gcore-label-checkbox" for="singleoccu3">Regular Fee - RM2450 per pax</label></div></div></div></div></fieldset><legend>Participant(s)</legend><div class="panel panel-default chronoform-container" id="participant-1-container">
					<div class="panel-heading">Participant #1</div>
					<div class="panel-body"><div class="form-group gcore-form-row" id="form-row-name1"><label for="name1" class="control-label gcore-label-left">Name (1)</label>
<div class="gcore-input gcore-display-table" id="fin-name1"><input name="name1" id="name1" value="" placeholder="" size="40" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-designation1"><label for="designation1" class="control-label gcore-label-left">Designation</label>
<div class="gcore-input gcore-display-table" id="fin-designation1"><input name="designation1" id="designation1" value="" placeholder="" size="40" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-phone1"><label for="phone1" class="control-label gcore-label-left">Phone</label>
<div class="gcore-input gcore-display-table" id="fin-phone1"><input name="phone1" id="phone1" value="" placeholder="" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-email1"><label for="email1" class="control-label gcore-label-left">Email</label>
<div class="gcore-input gcore-display-table" id="fin-email1"><input name="email1" id="email1" value="" placeholder="" class="validate[&#039;email&#039;] form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div></div></div><div class="panel panel-default chronoform-container" id="participant-2-container">
					<div class="panel-heading">Participant #2</div>
					<div class="panel-body"><div class="form-group gcore-form-row" id="form-row-name2"><label for="name2" class="control-label gcore-label-left">Name (2)</label>
<div class="gcore-input gcore-display-table" id="fin-name2"><input name="name2" id="name2" value="" placeholder="" size="40" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-designation2"><label for="designation2" class="control-label gcore-label-left">Designation</label>
<div class="gcore-input gcore-display-table" id="fin-designation2"><input name="designation2" id="designation2" value="" placeholder="" size="40" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-phone2"><label for="phone2" class="control-label gcore-label-left">Phone</label>
<div class="gcore-input gcore-display-table" id="fin-phone2"><input name="phone2" id="phone2" value="" placeholder="" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-email2"><label for="email2" class="control-label gcore-label-left">Email</label>
<div class="gcore-input gcore-display-table" id="fin-email2"><input name="email2" id="email2" value="" placeholder="" class="validate[&#039;email&#039;] form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div></div></div><div class="panel panel-default chronoform-container" id="participant-3-container">
					<div class="panel-heading">Participant #3</div>
					<div class="panel-body"><div class="form-group gcore-form-row" id="form-row-name3"><label for="name3" class="control-label gcore-label-left">Name (3)</label>
<div class="gcore-input gcore-display-table" id="fin-name3"><input name="name3" id="name3" value="" placeholder="" size="40" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-designation3"><label for="designation3" class="control-label gcore-label-left">Designation</label>
<div class="gcore-input gcore-display-table" id="fin-designation3"><input name="designation3" id="designation3" value="" placeholder="" size="40" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-phone3"><label for="phone3" class="control-label gcore-label-left">Phone</label>
<div class="gcore-input gcore-display-table" id="fin-phone3"><input name="phone3" id="phone3" value="" placeholder="" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-email3"><label for="email3" class="control-label gcore-label-left">Email</label>
<div class="gcore-input gcore-display-table" id="fin-email3"><input name="email3" id="email3" value="" placeholder="" class="validate[&#039;email&#039;] form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div></div></div><div class="panel panel-default chronoform-container" id="particiapant-4-container">
					<div class="panel-heading">Particiapant #4</div>
					<div class="panel-body"><div class="form-group gcore-form-row" id="form-row-name4"><label for="name4" class="control-label gcore-label-left">Name (4)</label>
<div class="gcore-input gcore-display-table" id="fin-name4"><input name="name4" id="name4" value="" placeholder="" size="40" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-designation4"><label for="designation4" class="control-label gcore-label-left">Designation</label>
<div class="gcore-input gcore-display-table" id="fin-designation4"><input name="designation4" id="designation4" value="" placeholder="" size="40" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-phone4"><label for="phone4" class="control-label gcore-label-left">Phone</label>
<div class="gcore-input gcore-display-table" id="fin-phone4"><input name="phone4" id="phone4" value="" placeholder="" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-email4"><label for="email4" class="control-label gcore-label-left">Email</label>
<div class="gcore-input gcore-display-table" id="fin-email4"><input name="email4" id="email4" value="" placeholder="" class="validate[&#039;email&#039;] form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div></div></div><div class="form-group gcore-form-row" id="form-row-approvename"><label for="approvename" class="control-label gcore-label-left">Approving Person’s Name</label>
<div class="gcore-input gcore-display-table" id="fin-approvename"><input name="approvename" id="approvename" value="" placeholder="" size="40" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-designationapprovename"><label for="designationapprovename" class="control-label gcore-label-left">Designation</label>
<div class="gcore-input gcore-display-table" id="fin-designationapprovename"><input name="designationapprovename" id="designationapprovename" value="" placeholder="" size="40" class="form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-approvephone"><label for="approvephone" class="control-label gcore-label-left">Phone</label>
<div class="gcore-input gcore-display-table" id="fin-approvephone"><input name="approvephone" id="approvephone" value="" placeholder="" class="validate[&#039;phone&#039;] form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-approvefax"><label for="approvefax" class="control-label gcore-label-left">Fax</label>
<div class="gcore-input gcore-display-table" id="fin-approvefax"><input name="approvefax" id="approvefax" value="" placeholder="" class="validate[&#039;phone&#039;] form-control A" title="" style="" data-inputmask="" data-load-state="" data-tooltip="" type="text" /></div></div><div class="form-group gcore-form-row" id="form-row-captcha"><div class="gcore-subinput-container-wide" id="fitem12"><label for="captcha1" class="control-label gcore-label-left">Captcha</label>
<div class="gcore-input pull-left gcore-sub-input gcore-display-table" id="fin-captcha1"><input placeholder="" size="5" class="validate[&#039;required&#039;] form-control A" title="" style="" type="text" name="captcha" id="captcha1" /><span class="help-block">Please enter the code in the image</span></div></div>
<div class="gcore-subinput-container-wide" id="fitem13"><div class="gcore-input pull-left gcore-sub-input gcore-display-table" id="fin-captcha2">{captcha_img}</div></div></div><div class="form-group gcore-form-row" id="form-row-submit6"><div class="gcore-input gcore-display-table" id="fin-submit6"><input name="submit6" id="submit6" type="submit" value="Submit" class="form-control A" style="" data-load-state="" /></div></div><div class="form-group gcore-form-row" id="form-row-custom4"><div class="gcore-input gcore-display-table" id="fin-custom4"><p><b>TERMS AND CONDITIONS</b></p>
<ul class="gkCircle1">
<li>For payment by local order, early bird fee will only apply if the Local Order is executed and send to the organizer on or before the early bird deadline.</li>

<li>If a duly registered participant is unable to attend, a substitute participant is welcomed at no additional cost. Please provide the name and the designation of the substitute participant at least 3 days prior to the course.  </li>

<li>Cancellation of registration must be made in writing (letter, fax or e-mail) to Emerge Knowledge Connection Sdn Bhd at least seven (7) working days prior to the event with 20% of the registration fee imposed for cancellation. The organizer regrets that any cancellation made less than seven (7) working days prior to the event shall not be accepted and full registration fees will be billed to the respective organisation.</li>

<li>The organiser reserves the right to make any amendments, cancel and/or change the programme, speaker/ trainer/ facilitator, date or venue should circumstances beyond the organiser’s control arise. The Organiser will inform the participant(s) if any changes arise. </li>

<li>In compliance with Personal Data Protection Act 2010, your personal information in our database will be safeguarded and will not be shared without your consent. Please visit www.emergekc.com.my for our Personal Data Protection Notice.</li>
</ul>


<p><b>PAYMENT METHOD</b></p>

<p>Payment can be made by Local Order (LO)/ crossed cheque or bank draft payable to <strong>EMERGE KNOWLEDGE CONNECTION   SDN BHD</strong>.</p>
<p>Public Bank A/C No : 3153574228</p> 
<p>Enclosed is our LO, crossed cheque/ bank draft for RM.............</p>  			

<p>

<b>Emerge Knowledge Connection Sdn Bhd</b><br>
No 43-3, Jalan Puteri 2/3, Bandar Puteri,<br> 47100 Puchong, Selangor<br>
Tel : +603-8063 5430 / +603-8027 7228;<br> e-mail: admin@emergekc.com.my</p>

</div></div>