REGISTRATION FORM
Date: 06-10 February 2019
(Please Write in Capital Letters)
Receipt Number:-___________________(For Office use only)
Dr Prof Mr. Mrs. Ms. please tick as appropriate)
* IAP MEMBER : Yes No *IAP Membership No. MCI/MMC Reg No
Title
...................................…………………………………
Non Member
PG Student
*First Name:……………………………………..……………………………..*Last Name: ………………………………………………………………………….
*Date of birth: _________/_________/__________Age:( ) Gender: Male Female/ Nationality:………………...……………..……..
Institute:………………………………………………………………… Designation:………………………………………………………………………………….
*Address:………………………………………………………………………………………………………………………………………………………………………….
*City:…………………………………………..…………….. State:………………………………………………………….. Pin Code:……………………………….
Country:……………………….. Phone:(With STD CODE)……………………………………… *Mobile ……....................…………………….……… ...………..
*Email : ……...................……………………………………………………………………………………………………………………………………………………….
Accompanying Person
Details:
…………………………..……………………………...........…………………………
Title: Full Name:……………………………………………………………………………………………….Age:…………………………. M F
Title: Full Name:……………………………………………………………………………………………….Age:…………………………. M F
Title: Full Name:……………………………………………………………………………………………….Age:…………………………. M F
Choice of Food : Vegetarian Non Vegetarian Jain
* PG student should submit the bona fide certificate from Head of the Department/Institution along with registration form. *Senior citizen need to submit their age proof.
Payment Details:
Conference ………………………………………………Accompanying person: …………………….…………….……..
Amount in Words:……………………………………………………………………………………………………...................................................…...…
Mode
CHeque/UTR No................................................................Bank Name.................................................Date...............................................
GST No:- 27AAATI5074J1ZG
of Payment: Online Registration/Cheque/NEFT (Please tick as appropriate)
Amount Paid for -
GST Amount ..............................................................................Total Paid ...................................................................................................
Signature:-__________________________________ Date:-___________________________
(Above 70 years) (Please tick as appropriate)
Organized by: Indian Academy of Pediatrics, Mumbai Branch | Venue: MMRDA Ground, BKC,Mumbai, Maharashtra
PEDICON 2019 MUMBAI 2019
+91- 22- 24045803/8424012019
Conference Secretariat Address:
[email protected] | [email protected]
56th National Conference of Indian Academy of Pediatrics
MUMBAI
No of Accompanying Person....................
Indian Academy of Pediatrics MUMBAI92/4, Gita Building, 1 st floor, OPP SION Bus depot,Sion Near Chaggan Mitha Petrol Pump, Sion Mumbai 400022
