ReGISTRATIon FoRm - Medical Gastroenterology Department

ISG Kerala Chapter Annual Conference 2015
April 18th - 19th
Hotel Uday Samudra Trivandrum
Kerala Chapter
Registration Form
Name
:
Address
:
Email :
Land Phone
:
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...............................................................................................................
................................................................Pincode..................................
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............................................Mob :........................................................
Registration Tariff
Categories
Delegate
Rs. 1000/-
Rs. 1,500/-
Accompanying Person
Rs. 1000/-
Rs. 1,500/-
PG Student
Rs. 500/-
Rs. 750/-
Catergory : Delegate
Upto 10/04/2015
Accompanying Person From 11/04/2015 & Spot
PG Student
All payments by Demand Draft / Cheque in favour of Trivandrum Liver Clinics, Payable
at Trivandrm
Cheque/ Draft No : .......................Date ...................Rs...................................................... ..
................................................................... Bank...............................................................
Send the duly filled registration forms along with DD/cheque to the conference secretariat
Postgraduate students should submit a bonafide certificate from Head of the department /
Institution.
Please add out station fee of Rs. 40/Date :
Accommodation at Venue
Check in 18th April Check out 19th
April Tariff Rs. 3750/- per room per
night on single /double occupancy ba
sis/ complementary breakfast.
Signature
Conference Secretariat
Department of Medical Gastroenterology
Super Speciality Block, Medical College
Thiruvananthapuram-695011
[email protected] | www.gastrotmc.org
Ph : 0471 2528783
ISG Kerala Chapter Annual Conference 2015
Workshop on EUS April 18th
Venue : Endoscopy Suite, Super Speciality Block,
Medical College, Trivandrum
Kerala Chapter
Registration Form
Name
: ...............................................................................................................
Address
: ...............................................................................................................
...............................................................................................................
...............................................................................................................
..............................................................Pincode....................................
Email : ...............................................................................................................
Land Phone
: ...................................................Mob :..................................................
Registration Fee : Rs. 500/All payments by Demand Draft / Cheque in favour of Trivandrum Liver Clinics, Payable
at Trivandrum.
Prior registration is mandatory : Registration restricted to 50 delegates on a first come first
serve basis.
Cheque/ Draft No : .......................Date ...................Rs...................................................... ..
................................................................... Bank...............................................................
Send the duly filled registration forms along with DD/cheque to the conference secretariat
Postgraduate students should submit a bonafide certificate from Head of the department /
Institution.
Please add out station fee of Rs. 40/Date Signature
Conference Secretariat
Department of Medical Gastroenterology
Super Speciality Block, Medical College
Thiruvananthapuram-695011
[email protected] | www.gastrotmc.org
Ph : 0471 2528783