1. Healthcare

Registration Form
2nd National Conference of
URBAN HEALTH SOCIETY OF INDIA
“Urban Health: Opportunity for Multi Sector Partnership”
4-5th April 2015 at Hotel Royal Orchid, Jaipur, Rajasthan
Name of the Participant: __________________________________________________
Designation: ______________________________________________________________
University/Organization: ___________________________________________________
Mailing Address: ___________________________________________________________
____________________________________________________________________________
City: ________________ State: ________________
Postal Code: _____________
Telephone: (O) _____________ (M) _____________________
Email: ______________________________________________________________________
Registration Fee (tick mark whichever is relevant)
Type of
Registration
Life Member
Member
Student
Early Registration:
20.2.15
Nearing Registration:
15.3.15
Late Registration:
3.4.15
On the spot
Registration
INR 1000
INR 1200
INR 750
INR 1500
INR 1800
INR 1000
INR 2000
INR 2200
INR 1500
INR 2500
INR 2500
INR 2000
*This is inclusive of service tax @ 12.36%
**Registration fees for international participants is $ 500 without accommodation
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Accommodation Required: Yes/No……………… (If yes, tick mark whichever is relevant)
Type of Hotel
Type of room
Rate single per
night
Rate twin sharing
per night
IIHMR Guest House
AC room/ Non AC room
INR 1500/ 1200
INR 750 /600
3 star Hotel
AC Room with Breakfast
INR 2500
INR 1500
5 star Hotel
AC Room with Breakfast
INR 4000
INR 2500
*This is inclusive of service tax @ 12.36%
Paper/Poster presentation (Tick):
In person
In absentia
Details of Cheque/ DD:
D D No/UTR no. :_______________ Dated: ____________
Drawn on (Bank)___________________ for Rs: _____________________________________
Payment should be made through a DD in favour of Institute of Health Management
Research, payable at Jaipur or through net transfer or NEFT, as per details given below :Bank Name : HDFC Bank Ltd.,
Branch address: D-54, Siddi Vinayak, Ashok Marg, C. Scheme, Jaipur-302001.
IFSC Code: HDFC0000054
Bank account no: C.A.No: 00540330002103.
Bank account holder name: Institute of Health Management Research.
Client Address: 1, Prabhu Dayal Marg, Sanganer Airport, Jaipur-302011, Rajasthan (India)
Date: _____________
Signature of the Participant: _________________
------------------------------------------------------------------------------------------------------------------------------All Correspondence including submission of papers should be addressed to:
Dr. Goutam Sadhu
Organising Secretary,
IIHMR University
1, Prabhu Dayal Marg
Sanganer Airport
Jaipur-302029, Rajasthan, India
Phone: 0141-3924700, 2791431-32, Ext: 718, Cell: 8107777867
Email: [email protected],
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