REGISTRATION FORM National Conference on Science & Technology for Human Development (March 20-21, 2015) Organised by The Indian Science Congress Association: Haridwar Chapter and Department of Ancient Indian History, Culture & Archaeology Gurukul Kangri University, Haridwar 249 404, Uttarakhand Full Name: _________________________________________ Designation: _________________________ University/Organization: __________________________________________________________________ Mailing Address: Prof./Dr./Ms./Mr. __________________________________________________________ City: __________________________________ State: ____________________ Pin Code: ______________ Phone / Mobile no.: __________________ E-mail: ________________________________ Title of the Paper: ________________________________________________________________________ _______________________________________________________________________________________ Additional Information: (b) Membership of Haridwar chapter: Member/ Non-member 1. Category: (a) Delegate/ Student [Attach the proof of membership, if already a member][strike out whichever is not applicable] 2. Indicate your interest: *Paper presentation Poster presentation Participation only *Abstract (100-200 words) should reach on or before March 03, 2015 via email: [email protected] Abstract and full paper should be typed in MS word in Times New Roman 12 Fonts. 3. Section (out of 14 sections given in brochure): 4. Accommodation Required: Yes No (Paid accommodation will be provided on shared basis with charges Rs. 500 per person) 5. Mode and Details of payment*: Draft/ Multicity cheque Demand Draft / Multicity cheque no.: Dated: Amount in Rs.: Name and address of issuing Bank: Cash Cancellations and Refunds: Any charges (Registration or accommodation) are non – refundable and non Transferrable. *For on spot registration, only cash payment will be accepted. All payment should be made in favour of ISCA Haridwar Chapter, Payable at Haridwar. Registration Fees Includes 02 Lunches, 01 Dinner, 01 Breakfast, Registration kit and proceedings. Please submit completed registration form with payment details to: Convener, ISCA: Haridwar Chapter Department of Chemistry, Gurukul Kangri University, Haridwar 249 404, Uttarakhand (INDIA), Phone: 9719250405, 07351739000, E-mail: [email protected], [email protected] Signature of participant Date:
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