" DELEGATE REGISTRATION FORM FOR THE 15TH INTERNATIONAL CONFERENCE 2012"

Name (in block letters) :
Father / Husband Name :
Date of Birth :
Sex :
Qualification
Present Address (in block letters) :
City :
Postal Zipcode / Pincode :

Country :

Permanent Address ( block letters) :
City :
Postal Zipcode / Pincode :

Country :

Phone :
E-mail :

Amount of Fees sent by M. O. / Draft :

Date :

Receipt No. / Draft No.

P. O. / Bank :

Apply For :

Ordinary Delegate Rs. 3000/-

Special Delegate (Awardees) Rs. 6000/-

Reception Committee Member Rs. 10000/-
Course Rs. 10000/-
Patron Rs. 25000/-
Fellow Member Rs. 10000/-
Associate Member Rs. 10000/-
Organizing Member Rs. 10000/-
Affiliation Rs. 45000/-
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I solemnly declare that the above facts are correct to the best of my knowledge and belief.

 

 

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