6th State Conference of IADVL TN Branch (10th www.cuticontn2015.com [email protected] & 11th October - 2015) CUTICON - TN 2015 REGISTRATION FORM Name : _____________________________________ Mobile: ____________________________________ Age:_______ Years Sex : Male/Female IADVL Membership no: ______________________ E-Mail id: _____________________________ Address: _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________ Pin Code_____________________________ City: _____________________________ State: ________________________________ Food Preference □ Veg □ Non-Veg DETAILS OF CO-DELEGATE: * (Registration mandatory for persons above 5 years) Name: ______________________________ Age: _______ Sex: Male/Female Veg/Non-Veg Name: ______________________________ Age: _______ Sex: Male/Female Veg/Non-Veg Name: ______________________________ Age: _______ Sex: Male/Female Veg/Non-Veg Name: ______________________________ Age: _______ Sex: Male/Female Veg/Non-Veg PAYMENT OPTIONS: Demand draft should be drawn in favour of CUTICON - TN 2015 payable at SALEM. DEMAND DRAFT DETAILS:Amount : Rs.________________________________ DD No. & Dated: ____________________________ Name of the Bank: ___________________________ Branch: ____________________________________ Signature: __________________________ Date : ____________________________________ * Please write your Name and write CUTICON - TN 2015 on the back of draft with mobile number. Please send to: CUTICON – TN 2015 Department of Skin & STD, Vinayaka Mission Kirupananda Variyar Medical College & Hospital, NH-47, Sankari Main Road, Chinna Seeragapadi, Salem - 636 308. Contact No.:- 9842788996 Organising Committee, Cuticon - TN 2015, Department of Skin & STD, Vinayaka Mission Kirupananda Variyar Medical College & Hospital, NH-47, Sankari Main Road, Chinna Seeragapadi, Salem - 636 308.
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