International Conference on Social Entrepreneurship 29th, 30th and 31st January 2015, Manipal, Karnataka, India Registration Form  Please use capital letters. Write name as you would want to appear on the certificate  Payment by demand draft to be drawn in favour of Manipal University Conference/ workshop payable at Udupi / Manipal Name: ___________________________________________________________________________________ Gender: M/F Designation: ___________________________________ Address: __________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Landline: ____________________ E-mail: _________________________________________________________ Mobile: _________________________ Preferred mode of communication: Post Participant Category: Research Scholars Email Telephone Academician Non-Governmental Organizations Industrialist/ Govt. Agency ___________________________________________________________________________ Details of payment: Registration fee: Rs __________ DD No: _________________ Dated: ____________ Drawn on (Bank): _________________________________________ Branch: Udupi / Manipal Unique Transaction Number : _______________________________ (In case of Online Payment) Date: Signature OFFICE USE ONLY Receipt No: ___________________________________ Date of receipt: _______________________________________ Remarks : __________________________________ Signature of Approving Authority Mailing address: Conference Chair, Dept. of Commerce, Near 10th Block MIT Hostels, Manipal University, Manipal Karnataka, India 576-104 Email: [email protected] For online payment bank account details are as below (need to send the above application by post/email). 1. Beneficiary Name & Address Manipal University Conference/Workshop Finance Department Manipal University Manipal-576104 2 Bank Account Number 33508958510 3. Name of the Bank State Bank of India 4. Branch Name & Address Manipal Branch Madhuvan Serai, Ground Floor Near Smrithi Bhavan Tiger Circle Manipal-576104 Udupi Dist. Karnataka, India 5. Account Type SB 6. IFSC Code SBIN0004426 7. MICR Code 576002006 8 SBININBB770 SWIFT Code Registration fee for Indian Participants: Till 10th November 2014 Rs. 1350 Rs. 1800 Rs. 2250 Rs. 2700 After 10th November 2014 Rs. 1500 Rs. 2000 Rs. 2500 Rs. 3000 Registration fee for Foreign Participants: Till 10th November 2014 Research Scholars USD225 NGOs USD270 Academicians USD270 Govt. Agency/ Industrialist USD360 After 10th November 2014 USD250 USD300 USD300 USD400 Research Scholars NGOs Academicians Govt. Agency/ Industrialist