LUCKNOW CAMPUS

REGISTRATION FORM

Council of Science and Technology, Uttar Pradesh sponsored

One day Seminar on “Intellectual Property Rights and Patents”

Organized by

Amity Institute of Pharmacy, Amity University Uttar Pradesh Lucknow Campus

On 1st February, 2018 Name of the Participant: Prof/Dr/Mr/Ms:

Occupation: Age: Gender:

Organization:

Address:

City: Phone No.: Email:

Category: Student/Research Scholar/Institution Delegate/Industry Delegate:

Local/Outstation:

Accommodation Required: If Yes From To

Payment Mode: Demand Draft Cheque Online payment Cash

Payment Detail: Paid Amount DD No/Cheque No. Dated:

Bank Name (withdrawn from): Branch City Zip Code

Details for Online payment: Name of Bank: Axis Bank Limited Account No. 053010100284066 Type of Account: Saving Account IFS Code: UTIB0000053

*Please send this form along with the demand draft at the following address:

Prof. (Dr.) Suneela Dhaneshwar Director, Amity Institute of Pharmacy & Deputy Dean Research (S& T),

Amity University Uttar Pradesh, Lucknow Campus Near Malhaur Railway Station, PO Chinhat, Lucknow-226028 (U.P.)

** Soft copy of duly filled form can be mailed at: sdhaneshwar1@lko.amity.edu