REGISTRATION FORM
TWO DAYS REFRESHER COURSE
Organized by
ITM SCHOOL OF PHARMACY
In association with
GUJARAT STATE PHARMACY COUNCIL
23rd and 24th February 2019
Email address *
Name (As per Pharmacy Registration Certificate): *
Your answer
Qualification: *
Current Designation: *
Your answer
Pharmacist Registration No. *
Your answer
Date of Last Renewal:
MM
/
DD
/
YYYY
Name and Address of Present Organisation: *
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Residential Address: *
Your answer
Mobile Number: *
Your answer
E - mail id: *
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Payment *
Cheque/Demand Draft No. and Date:
Your answer
For Further Information Contact:
Mr. Umang Gajjar
Coordinator
ITM School of Pharmacy, ITM Universe
Dhanora Tank Road, Off Halol Highway, Near Jarod, Paldi,
Vadodara, Gujarat 391510.
Contact Number: 02668 – 275508 Ext. 705 M: 09428806472, 9909039045
E-mail: gajjar_umang@yahoo.com, seminar.itmsop@itmuniverse.ac.in

Please e- mail scan copy of Registration Certificate of State Pharmacy Council on seminar.itmsop@itmuniverse.ac.in

A copy of your responses will be emailed to the address you provided.
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