33 IADVL AP STATE CONFERENCE AP CUTICON 2014 KURNOOL ON 18
33rd IADVL AP STATE CONFERENCE AP CUTICON 2014 KURNOOL ON 18st & 19nd October 2014 ORAGNIZED BY : IADVL AP STATE BRACH Auditorium Kurnool Medical College ,Kurnool REGISTRATION FORM To be Filled in Capital Letters Full Name ……………………………………………………………………………………………………………………… Age /Sex Type of Delegate Student Membership No Affiliation Postal Address ……………………………………………………………………………………………………………………… IADVL Member /Student ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… Email Fax Phone No Mobile Registration Category Member Non Member Accomp. Person PG (Provisional Life Member of IADVL) PG (Non Members) Before August 31st 2014 2000/2500/1500/1000/1500/- Before September 30th 2014 2500/3000/2000/1500/2000/- Spot 3000/3500/2500/2000/2500/- I am enclosing the DD/Cheque No …………………………….. Date …………………...... Drawn on Bank ……………………………….. For …………………………………………… in words ......……………………………………………………………………………………. in favor of “IADVL AP STATE BRANCH” payable at Kurnool. Conference Secretary Dr.S.Konda Reddy,M.D.,D.D 43/67,Narsinga Rao Peta ,3rd Line Kurnool-518004, Andhra Pradesh Email: [email protected] Mobile : +91-7674041258
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