73 5th to 8th FEBRUARY, 2015 New Delhi rd Dr. Rajesh Sinha

REGISTRATION FORM
73
rd
5th to 8th FEBRUARY, 2015 New Delhi
Dr. Rajesh Sinha
Chief Organizing Secretary
Room No. 474, Dr. R. P. Centre for Ophthalmic Sciences
AIIMS, New Delhi-110029, India
Email : [email protected] • Visit: www.aioc2015.com
2015
DELHI
Please write clearly in CAPITAL LETTERS.
Surname
Middle Name
Name
Institution ............................................................. Designation ................................... Age .............. Sex.............
Address ..................................................................................................................................................................
................................................................................................................................................................................
City ......................................... Pincode ............................ State ............................. Country ...............................
Tel. (Country, Area Code, Number) Work ...............................................................................................................
Mobile No. .............................................................. E-mail ....................................................................................
Nationality ................................................ Passport No. ...................................... Valid until (D.M.Y.)
(Not Applicable for Indian Citizens)
(Please write your mobile no. & e-mail id carefully for future communication.)
Delegate Category (Please Tick)
AIOS Member
Indian
Foreign
Non AIOS Member
Indian
Foreign
Resident
Indian
Foreign
Guest
Indian
Foreign
Trade
Indian
Foreign
AIOS Membership No.
Accompanying Person(s)
Name ................................................................................................................................ Age .............................
Name ................................................................................................................................ Age .............................
Name ................................................................................................................................ Age .............................
Name ................................................................................................................................ Age .............................
Registration Fee Paid Details
AIOS Member
INR / US$ ....................................
Non AIOS Member
INR / US$ ....................................
Resident*
INR / US$ ....................................
Guest
INR / US$ ....................................
Trade
INR / US$ ....................................
Other
INR / US$ ....................................
All Total
INR / US$
Food Preference :
Veg
Non Veg
Jain Food
Not Eating
For Office Use Only
Registration No.
Receipt No.
*Residents must furnish documentary evidence (Letter from HOD) along with registration form
P.T.O.
REGISTRATION FORM
73
rd
5th to 8th FEBRUARY, 2015 New Delhi
Dr. Rajesh Sinha
2015
DELHI
Chief Organizing Secretary
Room No. 474, Dr. R. P. Centre for Ophthalmic Sciences
AIIMS, New Delhi-110029, India
Email : [email protected] • www.aioc2015.com
Registration Fee Structure AIOC 2015 - Delhi
Please Category
Select
A. AIOS Members
Ophthalmologists
Residents / Trainees
Accompanying Spouse (Non Ophthalmologists)
B. AIOS Members – Senior Citizen
Senior Citizen – (> 70 & < 75 Yrs***)
Senior Citizen – (>75 Yrs***)
Spouse of Senior Citizen – (>70 & <75 Yrs***)
Spouse of Senior Citizen - (>75 Years***)
C. Non - AIOS Members
Ophthalmologists
Residents / Trainees
Accompanying Spouse (Non Ophthalmologists)
D. Trader
Trader
Early Bird
Upto
Nov 15, 2014
Rs.
USD
4500
90
3400
68
3400
68
Rs.
USD
2250
45
0.00
0.00
1700
34
0.00
0.00
Rs.
USD
6800
135
5100
101
5100
101
Rs.
USD
7200
140
Advance Rate
Nov 16 –
Dec 31, 2014
Rs.
USD
5600
110
4200
80
4200
80
Rs.
USD
5600
110
5600
110
4200
80
4200
80
Rs.
USD
8400
165
6300
125
6300
125
Rs.
USD
8700
170
Onsite Rate
Onwards
Jan 1, 2015
Rs.
USD
6800
135
5100
100
5100
100
Rs.
USD
6800
135
6800
135
5100
100
5100
100
Rs.
USD
10200 205
7600
150
7600
150
Rs.
USD
10400 210
Mode of Payment: All payments must be made by DEMAND DRAFT / AT PAR CHEQUE in favour of AIOC 2015 payable at New Delhi.
Please Note:
1) Registration fee for delegate includes: Delegate kit, admission to the scientific sessions, trade exhibition, inaugural
function, Lunch / Dinner / Banquet. Associate delegates are not eligible for delegate kit and entry to scientific sessions.
(Photo I-card of the delegate has to be shown at the registration counter for issue of kit bag)
2) Residents must furnish documentary evidence (letter from Head of the Department) along with registration form.
3) The secretariat does not accept liability for forms lost in transit.
4) For spot registrations: Complete kit would be subject to availability.
5) All foreign delegates / NRI are required to pay in US$ only, and the transaction charge has to be borne by the delegate.
6)
Members in various Government Services registering before the 1st cutout date can register without sending their
Delegate fees in advance. For claiming this privilege they should enclose a certificate from the Head of the Institution
to the effect that they are serving there (Article XX(6)(v) of the Bye Laws).
7) Those members who cannot do online registrations are requested to fill up the Registration Forms, enclosed the
relevant certificate and send the same to Conference Secretariat.
Cancellation & Refunds: Cancellation is permitted upto 31st December, 2014 whereby 25% of the registration fee would be
deducted as processing charges. Refund of registration fee will be made only against a written request submitted to the
Conference Secretariat, along with Identity Proof.
I am enclosing herewith Demand Draft / At par Cheque No. ...................................................... Dated ...............................
for INR / US$ .......................... INR / US$ (in words) ............................................................................................................
Drawn on (Name of Bank & Branch) ...................................................................... favouring “AIOC 2015”
Payable at New Delhi.
Signature of Delegate