Registration Form

CIDSCON 2015
5th Annual Conference of
The Clinical Infectious Diseases Society
21st - 23rd August, New Delhi
Prof.
Dr.
Mr.
Ms.
Name ..........................................................................................................................................................................................Gender : M
R e g i s t r a t i o n
F o r m
(PLEASE FILL IN CAPITAL LETTERS AS TO APPEAR IN THE CERTIFICATE)
F
Designation : ............................................................................................................Department* : ..............................................................................
Hospital / Institution : ......................................................................................................................................................................................................
Mailing Address : .................................................................................................................................................................................................................
City............................................................ Pin Code : .................................... State : ........................................... Country : .......................................
*E-mail:......................................................................................................................................................................................................................................
* Mobile: ...................................................................................................... * Ph. No. Res ................................................................................................
*State Medical Council Number: .......................................................
Registration Category :
Payment Details
Member Date of Birth: ......................................................... Age : ....................
Membership No. ______________________ Consultant
Post Graduate
Conference Fee : Rs. ______________________________
Cheque / DD No. : __________________________________
Date Drawn on Bank : __________________________________
Branch Non-Member
: __________________________________
: __________________________________
Amount in words : _________________________________________________________________________________________________________________
Date:
Signature
For Office use only
Receipt :
Date :
Reg No :
For online registration and payment visit : www.cidscon.in
Registration Fee
Category
Upto 31st March, 2015
Upto 31st July, 2015
Spot
Member
`. 3500
`. 5000
`. 7000
PG’s & Fellows
`. 2000
`. 3000
`. 4000
Non-Member
`. 4500
`. 6000
`. 8000
Note:
(a) Kindly attach a bonafide letter attested by HOD of the respective institution, which is mandatory for all the PG’s
(b) Mode of Payment : Cheque / DD to be drawn in favour of “Clinical Infectious Diseases Society” payable at Vellore.
(c) All refunds for cancellation will be done after the conference by deducting the administrative fees.
(d) Online fee @ 2.6% applicable for online registrations
Please submit the duly filled form and payment to the Conference Managers:
CIDSCON2015 (c/o Hallmark Events) #82/20, 1st Floor, 4th Cross, Brindavan Nagar, Mathikere Bangalore - 560054.
Ph: 080 23474500. Email : [email protected]