10th & 11th July 2015 at Royal Bengal Hall, City Centre, Salt Lake, Kolkata Name ............................................................................................................................................................. Affiliated Hospital.......................................................................................................................................... Address.......................................................................................................................................................... City................................................ State.................................................. Pin................................................ Phone (Mob).................................................................. (O)......................................................................... Email .............................................................................................................................................................. Registration fees : Delegates : Rs. 750 PGT : Rs. 500 The above amount is inclusive of service tax as applicable The cheque/ NEFT / RTGS / Bank transfer will be in the favour of “ILS HOSPITALS A/C LAPAROSCOPY 360 DEGREE”. The account details are as below: ILS HOSPITALS A/C LAPAROSCOPY 360 DEGREE Allahabad Bank, Beliaghata Branch Kolkata-700010 A/C N O. 50276549918 IFCS CODE: ALLA0210028 Payment Details: Amount (Rs.)................................................................................................. Mode : Cash / Cheque / DD DD / Cheque No. ............................................................................................Dated..................................... Drawn on ....................................................................................................................................................... Contact Dr. Om Tantia (9830400444) Dr. Tamonas Chaudhuri (9830067567) Mr. Sumit Sharma (9836365999) ILS Hospitals DD-6, Sector 1, Salt Lake City Kolkata – 700064 Email: [email protected]