MUMBAI CRITICON 2014 14th - 16th November 2014, Hotel Trident, Nariman Point, Mumbai. 14th November 2014 – Workshop 15th & 16th November 2014 – Main Conference Registration Form (Please fill in CAPITAL Letters) Title :  Dr.  Prof.  Mr.  Mrs. ISCCM Membership No. ___________________ Name : _______________________ ____________________________ ________________________ First Middle Last Mailing Address : _____________________________________________________________________ City : ______________________________ Pin : _________________ State : ______________________ Medical Registration No. _________________________ Tel. (with STD code) ______________________ E-mail : ________________________________________ Mobile No.: ___________________________ Accompanying Persons 1. Dr. / Mr. / Mrs. / Ms. / Mst. _______________________________________________________ 2. Dr. / Mr. / Mrs. / Ms. / Mst. _______________________________________________________ REGISTRATION (in INR) : Workshop 14th Nov. 2014 Upto 17 Aug 2014 th Main Conference 15th & 16th Nov. 2014 18st Aug 2014 to 31st Oct 2014 1st Nov 2014 onwards ISCCM Member 5,500 6,500 7,500 9,000 ISCCM Non – Member 5,500 7,000 8,000 10,000 Accompanying Person - 4,000 5,000 7,000 PG Student * 4,500 4,500 5,500 6,000 Nurses ** 1,500 3,500 3,500 3,500 - 5,000 5,000 5,000 Faculty * PG student is an ISCCM Registered student or a MD, diploma registered student only ** Main conference registration is not mandatory for attending Nurses CME INCLUSIONS :  Main Conference registration includes 2 Lunches, 1 Dinner, Tea & Snacks  Workshop registration includes 1 Lunch, Tea & Snacks  Conference Material (Not for Accompanying persons)  Taxes NOTE :        To register for the Workshop, it is mandatory to register for the Main Conference (except Nurses workshop) Nurses can register for only workshop, only conference or workshop & conference both. Limited seats for each workshop. Registration will be on first come first serve basis PG Students must submit a bonafide certificate from HOD/Institute Children above 5 years of age will be charged as full accompanying person (DOB if applicable) All the Remittance / Transaction charges are to be paid by the Registrant (for online registration) In case of non-realization of cheque a sum of Rs. 200/- will be charged additionally. WORKSHOP / CME : Kindly select any ONE of the following.  CME on Basic and Current Trends on Critical Care (Complementing the Advance Topics in Main Conference)  Renal Replacement Workshop - Emphasis on SLED and CRRT  Advanced Ventilation Workshop  Nursing CME PAYMENT :  To pay online via credit/debit card log on to “www.isccmmumbai.com”  Cheque/ DD, payable to “ISCCM MUMBAI BRANCH” Cheque/DD No. _____________________________ for Rs. _____________________________ Drawn on ______________________________________________________ Payable at Mumbai Add Rs. 100 for outstation cheques (not required for at par cheques).  Bank Transfer : A/c No. 319402010025130; Union Bank of India, Tardeo Branch, RTGS/IFCS Code : UBIN0531944 ________________________________ Signature If you need special assistance kindly contact CONFERENCE SECRETARIAT : FTC Events, M-33, Cusrow Baug, S. B. S. Road, Colaba, Mumbai – 400 039 Tel.: +91 22 2282 5108 Email – [email protected]