Name: _______________________ Gender: Male /Female Email id: __________________ Contact Number: Designation: 1st year MDS / 2nd Year MDS/ 3rd year MDS / Faculty Affiliated institution and address: __________________________________________ __________________________________________ __________________________________________ Are you a member of IAPHD: Yes/ No If Yes, Membership No: ______________ Accompanying person if any: _______________ Have you done your BDS/MDS from MCODS Manipal/Mangalore : Yes/No __________________ _____ ____________________ Signature Signature and seal of the HOD * (For PGs Only) Online transaction details: ______________________ Registration amount and details: Registration August 15th 2015 October 25th 2015 Spot registration Faculty Delegate 10500 11500 12500 Student Delegate 9000 10000 11000 Accompanying person (non-IAPHD member) 5000 6000 7000 Banquet only 3000 3000 3000 Non IAPHD Delegates (Other specialties) 13000 14000 15000 International delegates $450 $500 $550 For faculty registration queries, please contact: Dr Nishu Singla (9964504403); Dr Deepak Kumar Singhal (9379060983) For post graduate registration queries, please contact: Dr Kush Kalra (7259590022); Dr Raashi Raj (9901727349) Please ensure that scanned copy of the remittance details is sent by email to [email protected] or by post to organizing committee Payment details: 1 Beneficiary Name & Address 2 Bank Account Number 3 Name of the Bank 4 Branch Name & Address 5 Account Type 6 IFSC Code 7 MICR Code 8 SWIFT Code Manipal University Conference/Workshop Finance Department, Manipal University, Manipal 33508958510 State Bank of India Manipal Branch, Madhuvan Serai, Ground Floor, Tiger Circle Manipal-576104, Udupi SB SBIN0004426 576002006 SBININBB770 Please ensure that scanned copy of the remittance details is sent by email to [email protected] or by post to organizing committee Postal Address : Dept. of Public Health Dentistry, Conference Secretariat, 20th National Conference of IAPHD, Manipal College of Dental Sciences Madhav Nagar, Manipal University, Manipal Udupi district, Pincode – 576104, Karnataka.