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: