Offline Registration and Abstract Submission Form Thank you for expressing interest to participate as delegate at IPHACON-2016 schedule from 4th – 6th March 2016 at Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Swami Ram Nagar, Jolly Grant, Dehradun, Uttarakhand, India. Kindly send the filled Registration form along with DD / Cheque and/or Abstract in the format provided to Conference Secretariat (address given below) by speed post / Regd. Post/ Courier. Abstract will be processed only after realization of registration fee submitted by DD / Cheque. Your email address is the basis for all future communication with you, so please type it carefully. Personal Information Title: ……… First Name: ………………………………Middle Name: ……………………… Last Name: ……………………………....... Gender: ………………Date of Birth: ……………… E Mail ID: ...................................................................................... Institution / Organization: …………………………………………………………………………………. Position: …………………………………… Contact Information Address: ....................................................................................................................................................................... ……………………………………………………………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………………………………………………………….. City: …………………………………………Distt: .....................................Pin-code: ………………….Country: …………………………… Mobile Phone: …………………………………............Phone Office: …………………………….. Phone Residence: …………………….. Registration Fee TYPE IPHA Member IPHA Non Member PG Member PG Non Member Accompanying Person Pre Conf Workshop Early Bird Reg up to 31stOct 2015 Rs. 4,000.00 Rs. 4,500.00 Rs. 3,000.00 Rs. 3,500.00 Rs. 2500.00 Rs. 1000.00 Reg before 31stDec 2015 Reg before 28thFeb 2016 Spot Registration Rs. 4,500.00 Rs. 5,000.00 Rs. 3,500.00 Rs. 4,000.00 Rs. 3000.00 Rs. 1200.00 Rs. 5,000.00 Rs. 5,500.00 Rs. 4,000.00 Rs. 4,500.00 Rs. 3500.00 Rs. 1500.00 Rs. 6000.00 Rs. 6500.00 Rs. 4500.00 Rs. 5000.00 Rs. 4000.00 Not Applicable Cancellation (with 50% reimbursement of Delegate Fee only) before 31 Jan 2016. Payments Details Registration Fee Accompanying Person Pre Conference Workshop Total Mode of Payment Demand Draft/Cheque should be drawn in favour of IPHACON-2016, payable at SBI, HIHT, Jolly Grant, Branch Code - 10580 1. Demand Draft: Name of Bank: ………………...................… Amount: ................DD No: …………… Date: ……………… 2. Cheque: Name of Bank: …………...................................... Amount: ................Chq. No. ..……………..Date……………… (Cheque Payable at par at all branches. In case of outstation cheque please add Rs 75/- extra) Office Records only Date of Receiving: …………… Name of Receiver: ……………............. Name of Verifier: ……………… Regd No:………… Abstract Submission Details Abstract will be processed only after realisation of registration fee submitted by DD / Cheque. You must read the below mentioned Guidelines before submitting your abstract. Abstracts must be typed in plain text without any formatting. Title of Your Presentation: Select Sub-Theme: Select Your Presentation Type: Presenting Author Name: Co Author Name 1: Co Author Name 2: Co Author Name 3: Co Author Name 4: Co Author Name 5: Enter Abstract in Text only (350 Words only) Co Author Affiliation 1: Co Author Affiliation 2: Co Author Affiliation 3: Co Author Affiliation 4: Co Author Affiliation 5: Guidelines  Background: statement of the public health issue that is addressed by your study; what is known and what is not known.  Study Question: one sentence stating your study question(s).  Methods: concise description of study design, data sources and analysis methods; including study limitations.  Result: key findings from data analysis and limitations.  Conclusions: summary statement of key findings.  Public Health Implications: statement of potential uses of this study for science, policy, programs, public or provider education.