I S H D C O N F E RE N CE 2 0 1 5 From : 27th Feb to 1st March 2015 Venue : The Lalit, Sahar, Mumbai REGISTRATION FORM Title Prof. Dr. Mr. Ms. Name (in Block Letters) __________________________________________________________________________________ Male Female Resident/Fellow Faculty Address ______________________________________________________________________________________________ ______________________________________________________________________________ City _________________ PIN ___________ State _______________________________ Country __________________________ Telephone (W) (+ ) __________________________ (R) (+ ) _______________________ Mobile (+ ) _____________________________ Fax (+ ) ______________________________ e-mail __________________________________ ACCOMPANYING PERSONS Name Relationship Age Gender 1. _______________________________________________________________________________________________________________ 2.________________________________________________________________________________________________________________ REGISTRATION FEE DETAILS (Please refer to the Registration Tariff for various categories. Applicable on the date of registration) CATEGORY Until 15th Jan 2015 Until 15th Feb 2015 Spot Registration Delegate Registration RS.10,000 RS.12,500 RS.15,000 Delegate Registration with Accommodation (2 Nights) and all meals RS.25,000 RS.30,000 RS.35,000 Foreign Delegates Registration $ 200 $ 250 $ 300 Foreign Delegates Registration with Accommodation $ 500 $ 600 $ 700 Accompanying Person RS.10,000 RS,12,500 RS.15,000 Post Graduates RS.5,000 RS.6,250 RS.7500 Post Graduates Registration with Accommodation (2 Nights) and all meals - Twin Sharing RS.20,000 RS.25,000 RS.30,000 Dialysis Nurses & Technicians Registration (Outstation Nurses & Technicians can call or write to us for inexpensive accommodation) RS.1000 RS.1,500 RS.2000 Total Amount Rs. / US$ Choice of Food: VEG / NON-VEG PAYMENT In Words, Rupees _______________________________________________________ (Cash)/ (Transfer)/(remittance)/Cheque/Demand Draft No. _______________ Dated _______ Bank/Branch _________________ {The payment should be sent by demand draft, in favor of “Mumbai Nephrology Group,” payable at Mumbai. No out-station cheques will be accepted. For direct remittance use Bank of India, Mahalaxmi branch, Mumbai A/c. 002810110003683. For bank swift transfer please use Swift/IFSC Code is BKID000028 (Please intimate (mail the scan copy of the deposit receipt) to the conference secreteriat simultaneously about the remittance of the fee by bank transfer or direct remittance) . Date ______________________ Signature_________________________ Organizing Secretaries Dr.Bharat Shah Dr.Umesh Khanna The registration form duly signed, along with the payment should be sent to the Conference Secretariat Conference Secretariat Dinesh Nair Flat No 1, Ground Floor, Madhuban Building, Tejpal Road, Near Railway Station, Vile Parle (East), Mumbai 400 057 E mail : [email protected] Cell : +91 9320007375