REGSITRATION FORM

27-28 January 2018

Saturday-Sunday Name: ________________________________________________________ _______________

Membership No. Registration No. ___________________ Designation : __________________

Organiza tion: _________________________________________________ ________________

Org. Address Postal: __________________________________________ __________________

_____________________________________________________________________________

Phone No._______ _________________ __ Cell No. __________________ _________________

________________________________________________________ Email: _______________

Mode of Payment: By Crossed Cheque: Pay Order: Online Credit Card: ( For Members Only)

Signature of Partic ipant: ____ ___________

For Office Use Only

Receipt No. ____________ Date : _____/_____/2018 A mount Rs. ____ ___________ _______

Signature: ____ ______________