53rd Annual Conference of THE INDIAN ASSOCIATION OF PHYSIOTHERAPISTS (Shimla Branch) 20th, 21st & 22nd March, 2015 (Shimla, H.P) Registration Form S E C T I O N Name (Block letters): ............................................................................................... A E-mail ID: ................................................................................................................................ IAP Membership No. (if any): ............................................................................ PASSPORT Qualification: ...................................................................................................... PHOTO Catagory of Registration (tick) IAP Member (life) Students Foreign Delegates Non Member Spouse Mailing Address: .................................................................................................................... ................................................................................................................................................ Telephone No. : ...................................(Home)..........................................(clinic/office) Mobile No. : .............................................(Emergency)............................................ S E C T I O N B Till 15th Nov. 2014 Super early bird Till 30th Dec. 2014 Early bird Till 10th March. 2015 Spot Registration Late bird (If available) IAP Members Rs. 3000 Rs. 3500 Rs. 4000 Rs. 4500 Students Rs. 2500 Rs. 3000 Rs. 3500 Rs. 4000 Non members Rs. 3500 Rs. 4000 Rs. 4500 Rs. 5000 Foreign Delegates USD 100 USD 125 USD 150 USD 200 spouse Rs. 3000 Rs. 3000 Rs. 3000 Rs. 3000 Category DD to be drawn in favour of ‘’53 Annual conference of IAP’’ payable at ‘INDORE’ rd Fee (In amount)..................................................... (In words)...................................... ....................................................................................................................................... DD No.:............................................................. Date: ................................................. Bank: ............................................................................................................................ “NEVER BEFORE NEVER AGAIN....LET’S MOVE THE PHYSIOWAY...” Conference Secretarial: 53rd Annual Conference, Indian Association of Physiotherapists, Shimla Mob.: +91 9663407439, E-mail: [email protected] Website: www.iapcon.com