4th Annual 015 ABS ON- 2 IC Conference of Association of Breast Surgeons of India ABSICON-2015 INDORE (M.P.) Date : 26th to 28th June Venue : Hotel Radisson Blu Indore, (M.P.) REGISTRATION FORM Surname : ................................................ First Name : .............................................................................. Postal Address : ....................................................................................................................................................... ................................................................................................................................................................................. City : .............................. Pincode : ............................... State : .............................. Country : ................................... Email (please men on ac ve email ID) : ................................................................................................................... Tel. (with area code) Residence : ......................................... Oﬃce : ......................................... Mobile : .............................................. Fax : .............................................. Hospital : .................................................................................................................................................................. Consultant/ Trainee (please provide cer ﬁcate from HOD) ABSI Member/Non Member : ................................................................................................................................... All Future communica ons will be through email and mobile via SMS. Registra on Category (Tick the Category) Registration Packages : Residential Packages for 2 nights Residential Packages for 3 nights Delegate on twin Sharing (per person) Delegate on twin Sharing (per person) Member Delegate in Single Room Delegate in Single Room Non Member PG on Twin Sharing PG on Twin Sharing PG Student Mode of Payment : Cheque Bank Details : State Bank of India Branch Code : 030359 DD Account Name : ABSICON 2015 Non-Residential Packages Internet Payment Branch : MY Hospital, Indore Account No. : 34757225397 IFSC Code : SBIN0030359 MICR Code : 452005019 Cheque/DD No. : .................................................................................. Dated ....................................................... Drawn on : ....................................... Amount ..................................... Favouring : ABSICON 2015 payable at Indore Please send duly ﬁlled registra on form along with DD/Cheque to : Dr. Manish Kaushal Department of Surgery, Anand Mohan Mathur OT Complex, M.Y. Hospital, Indore, (M.P.) 452001 Phone : +91-93000 67722, E-mail : [email protected] | Web : absicon2015.com