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.