ISHD CONFERENCE 2015

Transcription

ISHD CONFERENCE 2015
I S H D C O N F E RE N CE 2 0 1 5
From : 27th Feb to 1st March 2015
Venue : The Lalit, Sahar, Mumbai
REGISTRATION FORM
Title
Prof.
Dr.
Mr.
Ms.
Name (in Block Letters) __________________________________________________________________________________
Male
Female
Resident/Fellow
Faculty
Address ______________________________________________________________________________________________
______________________________________________________________________________ City _________________ PIN ___________ State
_______________________________ Country __________________________
Telephone (W) (+ ) __________________________ (R) (+ ) _______________________ Mobile (+ ) _____________________________
Fax (+ ) ______________________________ e-mail __________________________________
ACCOMPANYING PERSONS
Name
Relationship
Age
Gender
1. _______________________________________________________________________________________________________________
2.________________________________________________________________________________________________________________
REGISTRATION FEE DETAILS (Please refer to the Registration Tariff for various categories. Applicable on the date of registration)
CATEGORY
Until 15th Jan 2015
Until 15th Feb 2015
Spot Registration
Delegate Registration
RS.10,000
RS.12,500
RS.15,000
Delegate Registration with Accommodation (2 Nights) and all meals
RS.25,000
RS.30,000
RS.35,000
Foreign Delegates Registration
$ 200
$ 250
$ 300
Foreign Delegates Registration with Accommodation
$ 500
$ 600
$ 700
Accompanying Person
RS.10,000
RS,12,500
RS.15,000
Post Graduates
RS.5,000
RS.6,250
RS.7500
Post Graduates Registration with Accommodation (2 Nights) and all
meals - Twin Sharing
RS.20,000
RS.25,000
RS.30,000
Dialysis Nurses & Technicians Registration (Outstation Nurses &
Technicians can call or write to us for inexpensive accommodation)
RS.1000
RS.1,500
RS.2000
Total Amount Rs. / US$
Choice of Food: VEG / NON-VEG
PAYMENT
In Words, Rupees _______________________________________________________ (Cash)/ (Transfer)/(remittance)/Cheque/Demand Draft No.
_______________ Dated _______ Bank/Branch _________________
{The payment should be sent by demand draft, in favor of “Mumbai Nephrology Group,” payable at Mumbai. No out-station cheques will be accepted.
For direct remittance use Bank of India, Mahalaxmi branch, Mumbai A/c. 002810110003683. For bank swift transfer please use Swift/IFSC Code is
BKID000028 (Please intimate (mail the scan copy of the deposit receipt) to the conference secreteriat simultaneously about the remittance of the fee by
bank transfer or direct remittance) .
Date ______________________
Signature_________________________
Organizing Secretaries
Dr.Bharat Shah
Dr.Umesh Khanna
The registration form duly signed, along with the payment should be sent to the Conference Secretariat
Conference Secretariat
Dinesh Nair
Flat No 1, Ground Floor, Madhuban Building, Tejpal Road, Near Railway Station, Vile Parle (East), Mumbai 400 057
E mail : [email protected]
Cell : +91 9320007375

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