registration and accommodation form
Dr. DS Deenadayal Dr. Srinivas Kishore Org. Chairman Org. Secretary Category Single Double Taj Krishna Rs. 9500 Rs. 12000 Venue Taj Banjara Rs. 6500 Rs. 8500 1 km Taj Deccan Rs. 6500 Rs. 8500 0.5 km Grand Hyatt Rs. 10000 Rs. 12000 3 km ITC Kakatiya Rs. 10500 Rs. 12000 3 km The Park Rs. 7000 Rs. 8000 2 km Raddison Blue Rs. 5500 Rs. 7000 2 km Golconda Rs. 5500 Rs. 6500 2 km Fortune Vallabha Rs. 4000 Rs. 5000 1.5 km Fortune Katriya Rs. 3500 Rs. 4500 2.5 km NKM Grand Rs. 2500 Rs. 3500 0.5 km Sitara Grand Rs. 2000 Rs. 3000 1.5 km Minerva Grand Rs. 2500 Rs. 3500 2 km Ohris Rs. 2500 Rs. 3500 2 km Distance from Venue IASSACON 2015 3 Annual Conference of Indian Associa on of Surgeons for Sleep Apnoea Affiliated to World Associa on of Sleep Medicine Date : 16, 17, 18 January , 2015 Venue : Hotel Taj Krishna, Hyderabad REGISTRATION AND ACCOMMODATION FORM Please complete in CAPITAL le ers only Title : Prof. Dr. Mr. Ms. Name................................................................ .......................................................... ........................................................ First Last Middle Designa?on............................................................... Ins tu on......................................................................................... Address.................................................................................................................................................................................. ............................................................................................................................................................................................... City........................................... State........................................ Country....................................... Pincode........................... Mobile ................................................................................... Tel (O)...................................... (R)....................................... Fax ............................................................. Email................................................................................................................... Category IASSA Member Non Member Post Graduate Accompanying person Foreign Delegate *Cer ficate from Head of Department is mandatory for P.G. students Workshop - Instruc onal courses (registra on is mandatory) 1) Sleep study 2) Sleep Endoscopy 3) PAP therapy Accompanying person/Spouse Name 1) ............................................................. 2) ............................................................. Total Registra on Charges....................................................................................................................................................... Accommoda on Details Hotel Preferences 1) ............................................................. 2) ............................................................. Check-in date .................................. Check-out date .................................. No. of Nights .............. No. of Rooms .............. No. of person ................................................................... Total Hotel Charges ................................................................... MODE OF PAYMENT Demand Dra? .................... Bank transfer .................. Cheque ................................ 1) You can pay be Demand Dra / Mul -city Cheque in favor of “IASSACON-2015” payable at Hyderabad DD/Ch. No...................................... Amount........................... Dated......................Bank....................................................... 2) By Wire Transfer / Bank Transfer Account No. 0276-03486064-195001 Bank : Catholic Syrian Bank, Secunderabad Branch, IFSC Code : CSBK0000276 CONFERENCE SECRETARIAT Dr. Srinivas Kishore NOVA Specialty Hospitals Dharani Devi Building, Adjacent to Volkswagen Showroom, Plot No. 565, Road No. 92, Jubilee Hills, Hyderabad 500 004 Tel. No. +91 9848018667 email : [email protected] website : iassacon2015.com Office use only Receipt No............................. Registra?on No......................
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