Registration Form - 13 March.cdr

HSICON 2015
9th Annual Hernia Society of India Conference 2015
10 - 12 September, 2015, Trident, Hyderabad
PERSONAL INFORMATION
Title : Mr.
Ms.
Mrs.
Dr.
Prof.
First Name: ……………………………….......................................……………...............….. Last Name: ……………...........................................………………………………………..
Organiza on: …………………...............……….....................................…........................................................................................................................……………...…
Address: ….………...………….........................................…………………………….............................................................................................................................……..
…………………………………………………..................…………………….............................................................................………………………….............................................…
City: ................................................. State: ................................................. Pin code: ............................................... Country: ................................................
Mobile Number: ................................................................................................. Email ………..……....................................………………………………………………………
REGISTRATION DETAILS :(please ck your registra on type)
Interna onal
Delegates
Na onal Delegates
(APHS/ HSI / IAGES )
Member
Non Member
Delegates
Accompanying
Person
PG
Students
Early Bird
(Before 31 May 2015)
Before
(30th July 2015)
250$
INR 6000
INR 6500
INR 3500
INR 4000
350$
INR 7500
INR 8000
INR 4500
INR 4500
Before
(30th August 2015)
400$
INR 8500
INR 9000
INR 5000
INR 5000
A er
(30th August 2015)
450$
INR 10000
INR 11000
INR 6000
INR 5500
INHOUSE REGISTRATION PACKAGE 2 NIGHTS / 3DAYS
Single/Double
Interna onal
Delegates (INR)
Single /Double
Na onal Delegates (APHS/
HIS/IAGES) Member (INR)
Single/Double
Non-Member
Delegates (INR)
Single/Double
Accompanying
Person (INR)
Single/Double
PG Students (INR)
Early Bird
(Before 31 May 2015)
Before
(30th July 2015)
488/378$
31720/24570
588/478$
38220/31070
21480/14340
21980/14840
18980/11840
19480/12340
22980/15840
23480/16340
19980/12840
19980/12840
Before
(30th August 2015)
638/528$
41470/34320
688/578$
44720/37570
23980/16840
24480/17340
20480/13340
20480/13340
25480/18340
26480/19340
21480/14340
20980/13840
A er
(30th August 2015)
Check in - 10th Sept 2015 I Check out - 12th Sept 2015
INHOUSE REGISTRATION PACKAGE 3 NIGHTS / 4 DAYS
Single/Double
Interna onal
Delegates (INR)
Single /Double
Na onal Delegates (APHS/
HIS/IAGES) Member (INR)
Single/Double
Non-Member
Delegates (INR)
Single/Double
Accompanying
Person (INR)
Single/Double
PG Students (INR)
Early Bird
(Before 31 May 2015)
Before
(30th July 2015)
607/442$
39460/28730
707/542$
45960/35230
29220/18510
29720/19010
26720/16010
27220/16510
30720/20010
31220/20510
27720/17010
27720/17010
Before
(30th August 2015)
757/592$
49210/38480
31720/21010
32220/21510
28220/17510
28220/17510
A er
(30th August 2015)
807/642$
52460/41730
33220/22510
34220/23510
29220/18510
28720/18010
Check in - 9th Sept 2015 I Check out - 12th Sept 2015
Total Amount (INR - in words) : ................................................................................................................................................................................................
PAYMENT DETAILS (please choose your preferred mode of payment)
PAYMENT MODES : Credit Card : VISA
Master
American Express
Note : 2.5% Transac on charges will be applicable on Visa & Master Card & 3.9% Credit Card bank charges will be applicable on American Express.
I ...................................................................................................................., here by authorize M/s. Le Passage to India Tours & Travel Pvt. Ltd., to charge
my Credit Card no. ............................................................................... (Master / Visa) valid up to .................................. for INR...........................................
In Words ............................................................................................................................................... as the charges towards the registra on for this
Conference. CVV NO. (VISA/MASTER) - 3 Digits .......................................................... (American Express) - 4 Digits ..............................................................
Name as on Card ..................................................................................................................................................Amount ......................................................
Signature ................................................................
DD / CHEQUE : Payments should be made by Demand Dra /Cheque in favour of "HSICON 2015" payable at Hyderabad. Kindly indicate your
name, contact number and name of the conference "HSICON 2015" at the back of DD/ Cheque and send it along with the duly filled form to the
address given below:
HSICON 2015 Conference Secretariat
Global Hospitals
6-1-1070/1 to 4, Lakdi-ka-pool, Hyderabad - 500004, Telangana
Mob. : +91 9908534882 I Tel. : +91 40 23244444
Email : [email protected]
DD / Cheque No.: ....................................................................................................... Date: .............................................. Amount: ......................................
Bank & Branch Name: ........................................................................................................................................................ Signature: ....................................
BANK TRANSFER
Bank Details
Name : Hernia Society of India Na onal
Bank : Indian Overseas Bank
Branch : Lakdikapul Branch, Khairatabad, Hyderabad
Acount no : 043702000002115
IFSC Code : IOBA0000437
MICR Code : 500020006
Please send the copy of the bank slip along with the duly filled form at [email protected]
Registra on fee will include
1. Admission to congress session, live workshop, exhibi on, 3 lunches, 2 dinners including banquet dinner on 11th September 2015.
2. Morning & a ernoon – tea/snacks
3. Congress bag and materials
4. Cer ficate of a endance
5. For accompanying persons only 3 lunches, 2 dinners and morning & a ernoon tea/snacks only. They would not be provided with cer ficates or bags
Note :
1. Dollar conversion rate is 1 USD = INR 65
2. The above rates are inclusive of taxes
3. All Cheques and DD to be made in favor of “HSICON 2015” payable at Hyderabad.
4. We only accept AT PAR and local Cheques.
5. Outsta on cheques will be taken with an addi onal amount of INR 100 as handling charges.
6. PG students should enclose a cer ficate from the Head of Department.
7. In-house registra on is applicable only for the venue hotel (Trident)
8. The In-house registra on package is inclusive of taxes on room
9. Govt taxes are subject to change. Taxes during the me of conference will be applicable
10. The In-house registra on package for Double room pricing have to be shared by two delegates for a room.
Cancella on & Refunds :
1. Cancella on will be accepted ll 31st August 2015. An amount equivalent to 50% plus bank charges for the total amount paid will be deducted as
handling charges.
2. For cancella on wri en request along with original “acknowledgement le er” should be sent to Conference Secretariat.
3. No Cancella on will be acceptable a er 1st Sept 2015.
4. Refund will be sent by cheque a er the conference.
FOR ANY ASSISTANCE PLEASE CONTACT
ICE - Integrated Conference & Event Management
(A Division of Le Passage to India Tours & Travels Pvt Ltd)
H.no-3-5-874/19/7&8, 2nd Floor, Hyderguda, Hyderabad -500029
Mob. : +91 9910662044
Email : [email protected]; Web : www.tui-ice.in