LUCKNOW CAMPUS REGISTRATION FORM National Symposium on “Interfacing Chemical Biology & Drug Design (ICBDD)” 24-25th Feb. 2015 Name of the Participant: Prof/Dr/Mr/Ms_______________________________________________________ Occupation: _______________________________________Age_______________Gender______________ Organization: ___________________________________________________________________________ Address: _______________________________________________________________________________ City: __________________Phone No.:__________________ Email: _______________________________ Category: Student/Research Scholar/Institution Delegate/Industry Delegate: ___________________________ Local/Outstation: ________________________________________________________________________ Broad Area: ______________________________________Poster presentation (Yes/ No)_______________ Title of the Abstract (if yes): ________________________________________________________________ Accommodation Required: ________ Payment Mode: If Yes Demand Draft From ___________________ To _____________________ Cheque Online payment Cash Payment Detail: Paid Amount___________ DD No/Cheque No.______________ Dated:__________ Bank Name (withdrawn from):______________________ Branch _________City____________Zip Code Details for Online payment: Name of Bank: Axis Bank Limited Account No. 053010100284066 Type of Account: Saving Account IFS Code: UTIB0000053 SELF DECLARATION I, Prof./Dr./Ms./Mr.__________________________ declare that paper entitled _________________________ ________________________________________________________________________________________ is my original research work which has not been published or sent for publication anywhere. Date ________ Place ________ Signature___________________ Name______________________ *Please send this form along with the demand draft at the following address: Prof. (Dr.) Devdutt Chaturvedi Convenor ICBDD-2015 Amity Institute of Pharmacy, Amity University Uttar Pradesh(AUUP), Lucknow Campus, Malhaur (Near Railway Station), Gomti Nagar Extension, Lucknow-226028 (U.P.) ** Soft copy of duly filled form can be mailed at: [email protected]