Form - Dermacon kolkata

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DERMACON 2017
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Venue: Science City, Kolkata | Date: 12 - 15 January 2017
45th National Conference of Indian Association of Dermatologists, Venereologists & Leprologists (IADVL)
Registration Form
For office use only
Registration No _______________
Date
_______________
Amount
_______________
Receipt No
_______________
Checked by
_______________
(FILL IN CAPITAL LETTERS)
PHOTO
(compulsory)
Category (Please tickþ appropriate)
IADVL Member c
Non IADVL Members c
PG Students [PLM] c
Corporate Delegate c
Foreign Delegate c
Conferenc
l
a
eo
it on
f
a
PG Students [Non PLM] c
SAARC Country c
Medical Council Registration No.....................Registering Authority............................IADVL Membership No....................
N
45t
h
Dermatology spread its wings
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Name...............................................................................................................Age............................M c
F c
(as per Medical Council Certificate)
Veg c
Non Veg c
VL
Physical disabilities any special need at venue....................................................................................................................
Address..............................................................................................................................................................................
...........................................................................................................................................................................................
City...................................................Pin code.........................State...................................Country....................................
Phone(with STD/ISD Code).........................................................Mobile.............................................................................
Email..................................................................................................................................................................................
Accompanying Persons: Maximum 3 per delegate: (Children above 5 years of age will be charged full as for an accompanying person)
Name...............................................................................................................Age............................. M c
Veg c
F c Non Veg c
Name...............................................................................................................Age............................. M c
Veg c
F c Non Veg c
Name...............................................................................................................Age............................. M c
Veg c
F c Non Veg c
All future communication will be through email & mobile via SMS
Registration Includes West Bengal Govt. Service Tax
Conference / CME & Conference
Amount.................................
Pre-conference Courses / Workshop
Amount.................................
Accompanying Person: (Nos)................
Amount.................................
Extra Food Coupon (S)
Amount.................................
Total
Amount ................................
The payment of Rupees..............................................................................................................................................only
by Cheque / DD............................Dated...........................drawn on....................................................................................
in favor of “DERMACON 2017 WELFARE SOCIETY” payable at Kolkata & Payment through Credit/Debit Card (Last 4
digits of the card no.....................................................................)Date of Transfer........................................... & for Bank
Transfer(NEFT), Name of the Bank: ..............................................................................................................................
Bank Transaction ID: .........................................................................................Date of Transfer........................................
Bank Account Name: DERMACON 2017 WELFARE SOCIETY
Account Number: 129601000694, Account Type: Savings, IFSC Code: ICIC0001296, MICR Code: 700229062
Bank Name: ICICI Bank Ltd., Branch: Moulali, Kolkata, West Bengal, Branch Code: 001296
Instructions:
Registration is compulsory for all irrespective of the type of participation
Submit the confirmation certificate duly signed by the HOD for IADVL NON PLM PG students & a copy of dermatology
degree/diploma certificates for Non IADVL Members. (COMPULSORY)
Pre-conference workshop - first come first serve basis, limited seats, there will be no dinner.
No conference kit for Corporate Delegate
For Spot Registration, Conference Kit or any other gift is not Guaranteed.
All Refunds shall be payable after one month of the conference. Cancellation must be notified by 15 November 2016
Accompanying persons are entitled to only social programs and not the Scientific Sessions.
Online registration will be available up to 31st December 2016.
Only Cash/Card Swipe/DD will be accepted for spot registration at the venue (subject to availability)
Photography in Scientific are prohibited
No eatables allowed in Scientific area.
Date:..................................Place......................................................Signature..................................................................
Conference Secretariat:
JIMA HOUSE, ROOM NO- 7, 1st FLOOR,
53 CREEK ROW. KOLKATA 700014
PH: +91 8420188475
Email : [email protected]
Extra Food coupon for Accompanying Person
Accompanying person can have their lunch & dinner through food coupons purchased from Organising
Committee on CME day only and for any delegate having more than 3 registered accompanying person on
other days.