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REGISTRATION FORM
Name: Dr/ Mr / Mrs / Ms________________________________________________________________
Title of the Research Paper: ________________________________________________________________________________________________________________________________________________
Sex: (Male/Female) ___________________________________________________________________
Category :( Faculty/ Research Scholars / Students / NGO /Industry/Participant) ___________________Organization: ________________________________________________________________________Department: _________________________________________________________________________Designation: _____________________________________________________________________
Correspondence Address: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________Pin:_____________________________________ Phone No.:_______________________________E-mail: ______________________________________________________________________________
Mode of Presentation of Paper (Kindly Tick Options) [A]. Paper Presentation (___) [B]. PPT Presentation (___) [C].Web Conferencing / Absentia (___)
Payment Method: (Cash Deposit / NEFT/Wire Transfer/Paytm) _________________________________Payment Details:_____________________________________________________________________Issuing Bank: ___________________________________________________________________Amount & Date: __________________________________________________________________NEFT/RTGS/ Wire Transfer/Paytm Reference No.:______________________________________Scanned copy of Cash Deposit receipt attached (Yes/ No) ____________________________________Name of the Accompanying person if any:
1) ________________________________
2) ________________________________
3) ________________________________
4) ________________________________
Registration Details
Faculties/Professionals 1500₹Students/Research Scholars 1000₹Accompanying person If any 800₹Note: The authors and Co-authors both must register separately
Accommodation Accommodation Required (Yes/ No):______________________________________________________Whether paid extra for Accommodation____________________________________________________( 1000 per person/Check in Check out Noon to Noon) ₹Duration from ________________________________________________________________________Date and time of arrival_________________________________________________________________Date and time of departure______________________________________________________________Mode of Travel (Bus/ Train/Air {Kindly Mention the details})_________________________________
Bank Details Name: Jageshwar Nath singh Bank Name: ICICI Bank Bank Address: NEW CANTT. ROAD, OPP HATHIBARKALA POLICE CHOWKI, DEHRADUN Pin 248001Account No. 016401564404Account Type: Savings IFSC Code: ICIC0000164MICR Code: 248229002
PAYTM NUMBER: +91-7579006367 (Mr. Dheeraj Kumar Tiwari)
Name: ________________________Date & Place __________________
Signature