MUMBAI CRITICON 2014 Registration Form (Please fill in CAPITAL Letters)  14

Transcription

MUMBAI CRITICON 2014 Registration Form (Please fill in CAPITAL Letters)  14
MUMBAI CRITICON 2014
14th - 16th November 2014,
Hotel Trident, Nariman Point, Mumbai.
14th November 2014 – Workshop
15th & 16th November 2014 – Main Conference
Registration Form (Please fill in CAPITAL Letters)
Title :

Dr.

Prof.

Mr.

Mrs.
ISCCM Membership No. ___________________
Name : _______________________ ____________________________ ________________________
First
Middle
Last
Mailing Address : _____________________________________________________________________
City : ______________________________ Pin : _________________ State : ______________________
Medical Registration No. _________________________ Tel. (with STD code) ______________________
E-mail : ________________________________________ Mobile No.: ___________________________
Accompanying Persons
1. Dr. / Mr. / Mrs. / Ms. / Mst. _______________________________________________________
2. Dr. / Mr. / Mrs. / Ms. / Mst. _______________________________________________________
REGISTRATION (in INR) :
Workshop
14th Nov. 2014
Upto
17 Aug 2014
th
Main Conference
15th & 16th Nov. 2014
18st Aug 2014 to
31st Oct 2014
1st Nov 2014
onwards
ISCCM Member
5,500
6,500
7,500
9,000
ISCCM Non – Member
5,500
7,000
8,000
10,000
Accompanying Person
-
4,000
5,000
7,000
PG Student *
4,500
4,500
5,500
6,000
Nurses **
1,500
3,500
3,500
3,500
-
5,000
5,000
5,000
Faculty
* PG student is an ISCCM Registered student or a MD, diploma registered student only
** Main conference registration is not mandatory for attending Nurses CME
INCLUSIONS :
 Main Conference registration includes 2 Lunches, 1 Dinner, Tea & Snacks
 Workshop registration includes 1 Lunch, Tea & Snacks
 Conference Material (Not for Accompanying persons)
 Taxes
NOTE :







To register for the Workshop, it is mandatory to register for the Main Conference (except Nurses workshop)
Nurses can register for only workshop, only conference or workshop & conference both.
Limited seats for each workshop. Registration will be on first come first serve basis
PG Students must submit a bonafide certificate from HOD/Institute
Children above 5 years of age will be charged as full accompanying person (DOB if applicable)
All the Remittance / Transaction charges are to be paid by the Registrant (for online registration)
In case of non-realization of cheque a sum of Rs. 200/- will be charged additionally.
WORKSHOP / CME :
Kindly select any ONE of the following.
 CME on Basic and Current Trends on Critical Care (Complementing the Advance Topics in Main Conference)
 Renal Replacement Workshop - Emphasis on SLED and CRRT
 Advanced Ventilation Workshop
 Nursing CME
PAYMENT :
 To pay online via credit/debit card log on to “www.isccmmumbai.com”
 Cheque/ DD, payable to “ISCCM MUMBAI BRANCH”
Cheque/DD No. _____________________________ for Rs. _____________________________
Drawn on ______________________________________________________ Payable at Mumbai
Add Rs. 100 for outstation cheques (not required for at par cheques).
 Bank Transfer : A/c No. 319402010025130;
Union Bank of India, Tardeo Branch,
RTGS/IFCS Code : UBIN0531944
________________________________
Signature
If you need special assistance kindly contact CONFERENCE SECRETARIAT : FTC Events, M-33, Cusrow Baug, S. B. S. Road, Colaba, Mumbai – 400 039
Tel.: +91 22 2282 5108 Email – [email protected]

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