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FORM-A
rd
63 National Conference of Anatomical Society of India
November 20-23, 2015
King George’s Medical University, UP, Lucknow, India 226003
REGISTRATION FORM
(PLEASE FILL IN CAPITAL LETTERS)
Title :
Dr.
Prof.
Mr.
Ms.
Life
Ordinary
ASI Membership Number
Mrs.
Name
(First Name)
Gender
(Middle Name)
Male_____________Female _____________
(Last Name)
Day
Date of Birth __________/__________/______________
Month
Year
Designation
Institution
Address
City
Pin code
State
Telephone No.
Mobile No.
Email ID
Emergency Contact
Name
Mobile Number
Food Preference
Veg
Non Veg
Registration Category
Life Member & Ordinary Member
* PG Students
Spouse & Associate delegate
International Delegate
Name/s of Accompanying Persons (including children above 12 yrs)
(1)
(4)
(3)
Registration Details
Conference
Pre Conference CME
Pre Conference Workshop
Spouse & Associate delegate
Children above 12 years
Accommodation
Total
Payment Details
Mode of Payment
(2)
Rs._________________
Rs._________________
Rs._________________
Rs._________________
Rs._________________
Rs._________________
Rs._________________
At par cheque
Demand Draft
DD/ Cheque number/
________________
Date of DD/ Cheque/
________________
Drawn on
________________
Attach Demand Draft/Cheque
Details of the bank account are as follows:
Bank Name:
Allahabad Bank,
Bank address:
K G M C, Chowk, Lucknow, UP-226003
Account Name:
"NATCON 63"
Account Number:
50249587388
Account Type:
Savings
IFSC Code:
ALLA0211028
SWIFT Code:
ALLAINBBLUK
DEMAND DRAFT Mode:
In favour of " NATCON 63 "
payable at Lucknow.
NEFT
NEFT Transaction ID
Date of Transaction
Your Account Number
Your Bank Name
Attach NEFT Confirmation Slip
________________
________________
________________
________________
Date ....................................
Place....................................
Please submit the duly filled form to Conference Secretariat :
Prof. A K Srivastava
Chief Organizing Secretary
63 NATCON of Anatomical Society of India
Professor & Head
Department of Anatomy,
King George's Medical University, UP, Lucknow, India 226003
Signature
Note :
* Only Delegates registering for the conference can participate in workshop
* DD/Cheque to be drawn in favour of “NATCON 63” Payable at Lucknow.
* Please attach a bonafide letter attested by HOD of the respective institution,
which is mandatory for all Post Graduate
* New members, kindly enclose the photocopy of ASI Membership receipt.