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COLOMBO INTERNATIONAL TRAUMA CONFERENCE - 2019
Event Date: July 11th, 12th - 2019
Event Timing: 8am - 4pm
Event Address: Neurotrauma Auditorium, NHSL, Colombo, Sri Lanka
Contact us : Email: colombotraumaconference@gmail.com
Telephone: 011 2 691111 (extension 2560)
Registration fee: Rs 2000/- ( for registered doctors -Registration fees can be reimbursed)

Rs 1000/- for medical students
Rs 2000/- for Nursing officers
Deposit the amount to :
BOC current account no: 0078685439
Account Name: Clinical Society of Accident and Orthopedic Services NHSL Colombo 10.
(If online payment enter account name as: CS AOS NHSL)
Branch : BOC- Regent street
(Please upload the payment receipt / screenshot of the online payment receipt, for the registration process to be confirmed and finalized)

Email address *
Full Name *
Name with initials *
First name *
For the name tag
How your name should appear on the certificate *
Email *
Mobile number *
Designation *
If answer is other - Please mention in question below
Other
Specialty / Area of practice *
If answer is other - Please mention in question below
If your answer is "other" to above question, state the specialty / area of practice
Hospital/ Institution *
e.g , P.G.H Badulla , D.G.H. Gampaha / B.H. Panadura / NHSL / Name of Private hospital
Date of Birth *
MM
/
DD
/
YYYY
University *
If your answer is " Overseas or Other" for above question, state the University
Post graduate qualification if any
SLMC Registration Number *
If not registered yet , indicate " No"
Meal Preference *
I understand that I have to pay Rs 2000/- (for doctors- reimbursable), Rs 1000/- (for medical students) and upload the payment receipt / screenshot of the online payment receipt below, for the registration process to be confirmed and finalized *
Please upload the scanned document / clear photograph / screenshot (if online transaction) of the payment receipt. *
Deposit Rs 2000/- to BOC current account no: 0078685439 Account Name: Clinical Society of Accident and Orthopedic services NHSL Colombo 10. (If online payment enter account name as: CS AOS NHSL) Branch : BOC- Regent street
Required
I hereby agree that the above information are true and correct according to my knowledge, and will check my email box and respond accordingly *
A copy of your responses will be emailed to the address you provided.
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