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The Patra Bali Resort & Villas
Jl. Ir. H. Juanda, South Kuta Beach Kuta
80361, Bali, Indonesia

Website: http://www.thepatrabali.com

Email: [email protected]

For hotel reservation, please complete the online Hotel Reservation Form by 28 June 2019. To enjoy the preferential rates during the AYIM course duration, please indicate the hotel code “AYIM1” on the Hotel Reservation Form.


Personal Details of Participant (Fields marked with *are mandatory)
Upload Photo *
Click here to upload

Your recent photograph image must be
- in colour taken against plain white background without shadows;
- show the full face;
- in business attire;

Your photograph image attachment file must be
- JPEG format ('jpg' extension)
- file size should be about 150 Kbytes;
- dimension of the photo image has to be 400 by 514 pixels;

Full Name *
Family Name/Surname*
Preferred Name on badge*
Year of Birth*
Highest Educational Level*
Others (Please specify below)
Name of Company*
Others (Please specify below)
Job Title / Designation*
Years of Management Experience*
Mailing Address *

Country *
Postal Code*
Telephone *
E-mail *
Secretary's E-mail (if any)
Catering Arrangements

Special Dietary Requirements:
Vegetarian Meal
No Pork, No Lard Meal

Contact Details of CEO/President
(An individual grade report will be issued to you at the end of the Programme, with a copy also sent to your Chief Executive Officer/President).
Family Name
Emergency Contact Details
Relationship with AYIM participant:
Contact Number:
Please note that you will be required to complete and sign an Indemnity & Undertaking Form on the first day of course.
Important Note: To ensure that the 10th AYIM applicants meet the admission criteria, as well as to maintain a diversified distribution of participants, all registrations received will undergo a screening process.

Please take note that participants should confirm their air tickets and hotel accommodation ONLY after they have received the Programme Confirmation e-mail from the Singapore College of Insurance.

We will inform the participants by 30 August 2019, if the 10th AYIM programme is confirmed and if you have been accepted into the programme.

Programme Fee Per Participant

The fee covers participation in all programme activities and study materials. The fee does not cover airfares and hotel accommodation.

Early Registration Fee
(extended to 31 July 2019)
Regular Fee
(after 31 July 2019)
Without Accommodation SGD 910.00 (USD 650.00) SGD 1050.00 (USD 750.00)

You will be informed of the status of your registration. Please do not book your air ticket until confirmation of programme is received.
I wish to register for Regular Fee
Total Fees Payable
Mode of Payment
By telegraphic transfer (in Singapore dollars) to :

Beneficiary: Singapore College of Insurance Limited
Bank Account No: 001-053726-1
Bank Name: DBS Bank Limited
Bank Branch: Shenton Way
Bank Address: 12 Marina Boulevard, Marina Bay Financial Centre Tower 3. Singapore 018982
Bank Code: 7171
Branch Code: 001
Swift Code: DBSSSGSG

* I will undertake to indemnify the organisers for all bank charges.
By Credit Card (VISA or MasterCard only)
Complimentary Code:
Cancellation / Substitution Policy

Any cancellation request received in writing before 28 June 2019 will be eligible for a full refund. Thereafter, any cancellation will not be eligible for any refund. However, the participant may be substituted at any time, before 13 September 2019.

Please check and print a copy of the completed online Registration Form, if needed, before submission.

The Programme Manager - Singapore College of Insurance (SCI) requires an individual's personal details for use in connection with this course registration purpose.

Please thoroughly check to ensure the correctness of all particulars, including the programme details, before you submit your registration.

For any participant who does NOT submit this registration personally, the individual concerned must ensure that he or she has given prior consent to anyone who does it on his or her behalf. The SCI does not take any responsibility for any such action.

I give consent to the holding, processing and using of my personal details provided for my programme registration purpose with the SCI.

I confirm that I have fully read and understood the SCI Privacy Policy (https://www.scicollege.org.sg/Home/Policy) that is available on the SCI Website.