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64th Annual Conference of the
NEUROLOGICAL SOCIETY OF INDIA (NSI)
17 - 20 December, 2015 | Hyderabad, India | www.nsicon2015.com
REGISTRATION FORM
Dr.
Mr.
Ms.
Mrs.
Prof.
Neurologist
Neurosurgeon
Full Name ______________________________________________________________________________________________________________________________
Institution/Company ______________________________________________________________________________________________________________________
Address_________________________________________________________________________________________________________________________________
City___________________________ Pincode__________________________ State _______________________________ Country ___________________________
Work Phone ____________________________ *Mobile _____________________________________ Fax ________________________________________________
*Email ____________________________________________________________ *Membership No. _______________________________________________________
*Mandatory
ACCOMPANYING PERSON/S DETAILS
(1) Name __________________________________________________________________________________________________________ Age _________________
(2) Name __________________________________________________________________________________________________________ Age _________________
REGISTRATION FEE STRUCTURE FOR NSICON 2015
Early Bird Registration Fee
Interim Fee
Regular Fee
Upto June 30
July 1 to Aug 31
Sep 1 to Oct 31
Member (NSI)
` 11,400
` 13,680
` 15,960
` 20,520
Non-Member
` 13,680
` 15,960
` 18,240
` 22,800
Accompanying Person
` 6,840
` 7,980
` 10,260
` 12,540
PG / Trainees
` 5,700
` 6,840
` 7,980
` 10,260
Neuro Nurses
` 5,130
` 5,700
` 6,270
` 7,410
Category
Spot Registration Fee
Workshop on 16th Dec 2015 at KIMS Hospital - ` 2,850
SAARC - NSI Member
$ 257
$ 314
$ 371
$ 428
SAARC - Non Member
$ 254
$ 342
$ 399
$ 513
Other Foreign Delegates
$ 285
$ 342
$ 399
$ 513
Foreign Accompanying
Delegates
$ 171
$ 228
$ 285
$ 342
Foreign PG/ Trainees
$ 171
$ 171
$ 228
$ 285
Workshop on 16th Dec 2015 at KIMS Hospital - $ 68.4
TOTAL AMOUNT: Mode of Payment: Cash
DD
(In gure):_____________________ Demand Draft in favor of "NSICON 2015"
Demand Draft No. ________________________ Dated ______________________ Amount______________________ Drawn on Bank_________________________
Date: ____________________ Signature: __________________________
TERMS & CONDITIONS (REGISTRATION):
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Participation fee includes: Conference participation, Delegate kit.
Conference lunches and 2 sessions tea coffee during the conference.
The registration fee does not include any travel cost, accommodation,
sightseeing tours or airport transfer.
While your safety is of utmost importance, the committee or the organisers will
take no responsibility for loss of belongings/ valuables or damage to property.
Only delegates registered in the international registration category will receive
an Invitation letter for Visa purpose.
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The rates are inclusive of Service Tax. However all bank fee/ charges will be
charged extra as applicable.
75% refund will be valid if the cancellation request is received on or before
30th Sept’15.
No refund requests will be accepted after 30th Sept’15.
Payment can be made Online or through Cheque/ DD in the name of "NSICON
2015”
Refund process will be initiated 30 days after the conference.
Managed by
Form and DD/Cheque to be posted to NSICON Secretariat Address:
nd
th
NSICON 2015 - Conference Secretariat: CIMGlobal India Pvt. Ltd. - No. 2, NG Complex, 2 Floor, 30 Cross,
Bannerghatta Road Layout, Jayanagar 4th T Block, Bengaluru - 560 041 ; Tel: +91 80 2608 0700 ; Fax: +91 80 2608 0702