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]