ISMPO ISO _Registration_Form2015

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 : dr_jyotibajpai@yahoo.co.in
ismpoiso2015@gmail.com
: 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