IORITIES IN POS T- LD C HI LD W OR HE AL PR DG REGISTRATION FORM Please fill the form in CAPITAL letters only TH M 15th APCP 53rd Annual Conference of Indian Academy of Pediatrics 5th APCPN Thursday 21st Jan, 2016 to Sunday 24th Jan 2016 Hyderabad International Convention Centre | Hyderabad, Telangana State, India C 15th APCP PEDICON 2016 5th APCPN Hyderabad, Telangana State, India Receipt No. : ................................................. *IAP Membership No. : ................................................... (For Office Use) *Title: Dr. Prof. Mr. Ms. (Please tick as appropriate) *Name: ........................................................................................................................................................................................................................................................................ Date of Birth: ................................................ Age.: .......................... Gender: Male Female / Nationality................................................................................ Institute :.................................................................................................................................... .Designation : ...................................................................................................... Address : .................................................................................................................................................. ................................................................................................................. *City: .....................................................................Pin: ....................................... State: ................................................................... Country: ...................................................... Telephone: (..........)......................................................................................................... *Mobile............................................................................................................................. *Email : ........................................................................................................................................................................................................................................................................ Accompanying Person(s) Details: (Children 5 Years & above ) 5 1. Name: .................................................................................................................................................... Age: ................................................ M F 2. Name: .................................................................................................................................................... Age: ................................................ M F 3. Name: .................................................................................................................................................... Age: ................................................ M F 4. Name: .................................................................................................................................................... Age: ................................................ M F Meal Preference: Veg. Non-Veg. Jain (please tick as appropriate) *Mandatory fields. *Senior Citizens age proof to be submitted. *PG to submit bonafide certificate from the HOD Registration Fee Category (Please Tick) ü Delegate ü Accompanying Delegate (5 Years & above ) IAP Member INR 7500 INR 10000 NON IAP Member INR 14000 INR 14000 PG. Student INR 7500 INR 7500 SAPA Delegate USD 225 USD 250 SAARC Delegate USD 250 USD 250 APPA Delegate USD 250 USD 300 Post Graduate SAARC/APPA/SAPA USD 200 USD 200 Nurses USD150 Foreign delegate USD 900 USD1000 NIL INR 10000 Sr. Citizen (above 70 Yrs. IAP Member Only) Early Bird Registration valid up to 15th March, 2015 | No Refund for Early Bird Registration Total Amount : ............................................... (In Words) : .................................................................................................................................................................................... I AM PAYING THE ABOVE AMOUNT BY FOLLOWING MODE 1) Wire Transfer Account Name: APCP PEDICON 2016 Account Number: 62395231265 Address: State Bank Hyderabad, Gunfoundry branch, Hyderabad,Telangana State IFSC/RTGS Code : SBHY0020066 Transaction Ref. No : ................................................................................................................ Dated : ............................................................................................................... 2) Demand draft Demand draft in favor of APCP PEDICON 2016 payable at Hyderabad DD No. : ....................................................................................................................................... Drawn on : ....................................................................................................... Branch : ......................................................................................................................................... Dated : ............................................................................................................. Date............................................... Signature..................................................... Conference Addresses 1. Conference Address Akshay Memorial Mother and Child Clinic, 1-18, Divya Shakti Complex, Greenlands Ameerpet Hyderabad - 500016, Telangana, India Tel.: +914023730312 | Mob.: +91 9848034599 Email.: [email protected] www.apcppedicon2016.in 2. Conference Address Niloufer Hospital for children & Women, Red Hills, Hyderabad 500004, Telangana, India Tel.: +914023394265 | Mob.: +91 9246574657 Email.: [email protected] www.apcppedicon2016.in Managed By: