Offline Registration and Abstract Submission Form - IPHACON-2016

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.