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.
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