EDUCATION Biennial National Conference of Indian Society of Medical & Paediatric Oncology and Indian Society of Oncology EARCH RES CONTROL JOINTISMPOISOCONFERENCE2015 Registration Form Date : ____________________ Title: Dr / Prof / Mr / Mrs / Ms Name : ___________________________________________________________________________________________________ ( As it should appear on your badge and certificate ) Age : __________________ Sex : Male Female Specialty : _____________________________________ Designation : ____________________________________________ Organization :____________________________________________________________________________________________ Address : ________________________________________________________________________________________________ __________________________________________________________________________________________________________ City : _______________________________ Pin : _____________________ State : ____________________________________ Mobile (mandatory) : _____________________________ Email (mandatory) : ____________________________________ Associate Delegates : 1. __________________________________________________________________________________ 2. __________________________________________________________________________________ Membership Number of : ISMPO Registration Fee for the conference : ( [ Category ISMPO/ISO Member Non Member(Delegate) PG Students Associate Delegate Interna onal Delegate ISO ] Your appropriate Category ) st Up to 31 July 2015 2500 3000 1000 3500 200 USD Up to 30th Sept. 2015 3000 3500 2500 3500 250 USD Spot Registration 10000 10000 10000 10000 800 USD Note: • Registra on is mandatory for all par cipants. • The registra on fee includes entry to all scien ﬁc sessions, Conference meals and delegate kit bag. • The category of Associate Delegate includes only spouse, children & other dependent family members, if any. Payment Par culars : Bank Transfer details : Account Name : Interna onal CMEs Oncology Account Number : 5020-000-3674364 Bank & Branch : Mumbai Prabhadevi IFSC Code : HDFC0000012 MICR Code : 400240006 Details of NEFT Transfer : Cheque/DD Details : (Cheque/DD Should be in favor of “Interna onal CMEs Oncology” payable at Mumbai) Cheque/DD Number : Note: · · · · Dated : Drawee Bank & Branch : Please send the ﬁlled form along with Cheque / DD, to the conference secretariat address given below. Please men on your Name, City and Mobile No. on the backside of Cheque / DD. Conﬁrma on e-mail will be sent a er realiza on of the Cheque / DD. The oﬃcial receipt of the registra on will be handed over to you at the registra on desk during the conference. Dr. Jyoti Bajpai Organizing Secretary, ISMPO ISO 2015 Mo. +91 9920640044 E-mail : [email protected] [email protected] : Contact Us : Conference Secretariat : Mr. Rajesh Sharma Nucleus, A-1107 Siddhi Vinayak Tower, Nr. DAV International School, Makarba, Off SG Ahmedabad-380051. Mo. +91 9374073521 Web : http://ismpo.org/ismpo-iso