EPIJNAN 2018 Registration form

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Title: Surname: First Name: Middle Name: *
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Institute / Hospital: *
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Address: *
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City: Pincode: *
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Payment Details: Payment by Cheque or DD should be in the favour of "Epijnan 2018" payable at Bangalore.Please mention your name and mobile number behind the Cheque or DD. In case of NEFT / RTGS please refer below. Pleasemention as 'EPIJNAN 2018' under remarks
Name of Account: ASTER DM HEALTHCARE LTD Bank: HDFC Branch: Sahakara NagarAccount Number: 50200016187853 IFSC Code: HDFC0001036 Remarks: EPIJNAN 2018
Cheque / DD No: Bank: Amount:
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Transaction No: Date: Amount:
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Registration Guidelines:
CME Registration is mandatory for Hands On Workshop.• Registration fees will be based on the date of receipt ofpayment.• Photocopy of Id Proof (DL/Passport/Election Card) of thedelegates is a must; please send it along with the registrationform.• Provide all the necessary details as required in the form; it willbe used for conference communication only.• Please preserve photocopy for your record.• PG students have to submit the confirmation certificate dulysigned by HOD (Compulsory).• Provide your updated email id; it will be used for the registrationand other conference communication.• Organizing Committee shall not be liable in any form in case ofchanges in date / venue due to unforeseen reasons.• Conference Organizers are not reponsible for postal delays /failure of delivery by post or failure of electronic communication.
Terms & Conditions
Last day forregistration -20/10/2018• Limited slots• Hands-on Trainingwith cadaver (limited)Includes• Conference Kit• Gala Dinner
For further infomation please contactMrs. Girija ShettyDepartment of NeurosciencesAster CMI HospitalNo 43/2, New Airport Road, NH.7Hebbal, Sahakara Nagar, Bengaluru,Karnataka - 560092 9739733331epijnan2018@gmail.comwww.asterbangalore.com
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