Delegate Registration Form
World Atheist Conference 2018
Dravidar Kazhagam Tamil Nadu, Atheist Centre Vijayawada & The Rationalists’ Forum Tamil Nadu Organise
World Atheist Conference January 5,6 & 7, 2018 - Tiruchirappalli
Name (in Block Letters) *
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Gender *
Date of Birth *
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Age
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Academic Qualifications
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Nature of occupation / profession, held
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Is a member of any progressive/rationalist organization? *
If Yes, name of the organization and its' affiliation, to any federation.
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Have you attended any World Atheist Conference, held earlier? *
If Yes, furnish brief details.
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Address for communication: *
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PIN /Zip Code: *
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State *
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Country *
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Food *
Mobile *
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Email Id
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Facebook
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Twitter
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delegate fee : Rs 500 & Abroad USD $ 50
Account Details :
Account Holder Name: DRAVIDAR KAZHAGAM
Bank Name: Indian Overseas Bank
Branch: Vepery
Account No: 232002000000016
Account Type: Current Account(CA)
IFSC CODE: IOBA0002320
Mode of remittance of the delegate fee, for Registration *
Online Banking Transaction Id / DD No /DKHEAD Voc.No: *
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Date *
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Bank Name *
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Amount *
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