SDUMC CME 2015 Registration Form Name: …………………………………………………………………………………………. Designation: ………………………………………………………………………................... PG/ Ph.D : ……………………………………………………………………………………… KMC/ State Medical Council Registration Number: ………………………………………. Institution Address: …………………………………………………………………………… .…………………………………………………………………………… Residential Address: …………………………………………………………………………. ..………………………………………………………………………… Mobile Number: ………………………………………………………………………………. E mail I.D ………………………………………………………………………………………… Payment: Amount may be paid through Cheque or Demand Draft in favor of: CME Department of Biochemistry, payable at Kolar. DD Amount:…………………… DD/ Cheque Number…………………………………………… Dated…………………………Name of Bank: …………………………………………………. Registration can also be made electronically through RTGS/NEFT: SB A/c No. 221010051639, ING Vysya Bank, Sri Devaraj Urs Medical College EC Branch, Tamaka, Kolar - 563 101. IFSC Code / NEFT / RTGS: VYSA0002210 Please confirm your registration by mailing Transaction details (scanned copy of DD/Cheque/NEFT) to [email protected] Date: Dr. Prabhavathi.K. Organizing Secretary, CME 2015 Dept. Biochemistry, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka. Pin: 563101 Mobile Number: +919481588279 Name & Signature