22 ISCCM CRITI CA ND RE re Medicine ual Ann Ca Co n f e ren ce ian Society of Cr Ind it al ic of 2016 Agra ‐ The City of Taj A Joint Meeting of 22nd Annual Conference of Indian Society of Critical Care Medicine International Sepsis Forum Conference: 5th-7th February, 2016 I Workshop: 8th-9th February, 2016 Venue: Jaypee Palace Hotel & Convention Centre, Agra Registration Form ISCCM MEMBER : Yes No Prof. Dr. Mr. Ms. (If Yes, Membership No. ............................................) (Please use Capital Letters only) Name:_____________________________________Surname:_____________________________________ Hospital :______________________________________________________________________________________________ Title/Position : _________________________________________________________________________________________ Mailing Address : _______________________________________________________________________________________ ______________________________________________________________________________________________________ City : __________________ State : ______________ PinCode : _________________ Country : _________________________ Tel. No. Hospital / Office : __________________________ Residence : ____________________ Fax : ___________________ Mobile No. : ______________________ E-mail : __________________________________________ Attending sessions : Paediatric Adult Both Accompanying Persons : Dr./Mrs./Mr./Ms. : __________________________________________________________ Age : _______________________ Dr./Mrs./Mr./Ms. : __________________________________________________________ Age : _______________________ Dr./Mrs./Mr./Ms. : __________________________________________________________ Age : _______________________ Please tick mark your choice at the reverse of the form and add the total figure Total Amount in Figure : / $ _________________________________________ Total Amount in Words : / $ _____________________________________________________________________________ Cheque / Draft No. : __________________________________ Dated : _____________________________ Drawn on Bank : _______________________________________________________________________________________ Mode of Payment : Cash Cheque Demand Draft in favor of “CRITICARE 2016” payable at Mumbai. (Add 100/- for Outstation Cheque) (For ONLINE Registration Please Visit www.criticare2016.com) Date _______________ Signature ____________________ Cancellation Policy up to 31st December 2015 After 31st December 2015 No Refund 50 % Refund Details of the account are as follows: Beneficiary Name : Criticare 2016 Bank Name : HDFC Branch Address : Shraddha Building, Dadar West, Mumbai Account No. : 50100074230391 IFSC Code : HDFC0001118 MICR Code : 400240147 For registration queries please contact CONFERENCE SECRETARIAT : Synergy Plus Hospital, NH-2, Near Guru Ka Taal, Agra - 282007 Mob.: +91-9927778889, +91-9837091030, +91-9837270140, +91-9837047812 Early Bird th 30 April 2015 Non - ISCCM Members st 1 May 30 June 2015 th st 1 July 31 Dec 2015 st 7,500 9,000 12,000 16,000 8,500 10,000 13,000 17,000 5,000 6,000 7,000 9,000 4,500 5,500 6,000 6500 450 550 600 650 150 250 300 350 200 250 300 350 100 150 250 300 1,500 2,000 2,500 3,000 Non Member 8th & 9th 40 7,000 8,000 175 8th & 9th 40 11,000 12,000 250 8th & 9th 5 17,000 8th & 9th 40 11,000 8th & 9th 5 17,000 8th & 9th 40 11,000 12,000 250 8th 40 7,000 8,000 200 6. 8th 40 5,500 6,500 175 7. 8th & 9th 40 5,500 6,500 175 8. 9th 40 5,500 6,500 175 9. 9th 40 7,500 8,500 200 10. 8th & 9th 40 11,000 13,000 250 11. Mechanical Ventilation 8th & 9th 40 8,000 9,000 200 1. Basic Advance 2. 3. 4. Airway 5. only for member 12,000 only for member 300 250 300 12. Trauma Support Course 8th & 9th 40 9,000 10,000 200 13. Nutrition 8th 40 6,000 7,000 175 14. Haemodynamic 8th & 9th 40 5,000 6,000 175 15. 8th & 9th 40 6,500 7,500 175 16. Nephro Critical Care 8th & 9th 40 7,000 8,000 175 17. 8th & 9th 40 7,000 8,000 175 18. 9th 40 7,000 8,000 175 19. Physical Rehabilitation and Respiratory Therapy 8th & 9th 40 5,000 6,000 175 20. Nursing Critical Care Course 8th & 9th 100 4,500 5,000 150 Organized by - ISCCM Agra Chapter Hosted by - ISCCM UP & Uttarakhand Chapter