Course on ECG in 4 Hours Organised by TACVI, Hyderabad Registration Form ----------------------------------------------------------------------------------------- Dates: 16th November 2014 Venue: Hotel Taj Banjara, Banjara Hills Time: 9.30am-2pm To, Dr. C. Raghu, Course Director Name (In Block Letters) Title First Name Speciality Gender Last Name Gender Institute Email ID (Mandatory) Mobile No: ______________________ Ph No.: ________________STD Code:_______ Address: Registration: Registration Fees Rs 1500 Please register me as a _________________, for ECG Course. I enclose here the fee vide NEFT/RTGS/Cash /Cheque / DD No. : _______________________ dated ____________ for an amount of Rs.______________________ in favour of “Training Academy for Cardiovascular Interventions”. Signature For Direct Deposits & NEFT / RTGS Fund Transfer: Indian Overseas Bank , Srinager Colony Branch Account: Training Academy for Cardiovascular Interventions Account No. 189002000000140 IFSC Code: IOBA 0001890 Please send the filled form to: Dr. C. Raghu, Cocoon Management Consltnts Roshan Basera, 10-5-8/8/A/2, Nr Canara Bank, Khaja Mansion Rd. Masabtank, 500028, Hyderabad, A. P. Ph: 09989335361, 09246105361 Write to us at: [email protected] www.interventionaltraining.com [email protected] www.cocoonconsultants.com --------------------------------------------------------------------------------------------------------------------------For office use only: Amount received Rs._____________ ______________Cash/Cheque/DD No.________________ dated ____________. Receipt No. _____________ Registration No.___________. Course Managed by Cocoon Management Consultants