ReGISTRATIon FoRm - Medical Gastroenterology Department
ISG Kerala Chapter Annual Conference 2015 April 18th - 19th Hotel Uday Samudra Trivandrum Kerala Chapter Registration Form Name : Address : Email : Land Phone : ............................................................................................................... ............................................................................................................... ............................................................................................................... ............................................................................................................... ................................................................Pincode.................................. .............................................................................................................. ............................................Mob :........................................................ Registration Tariff Categories Delegate Rs. 1000/- Rs. 1,500/- Accompanying Person Rs. 1000/- Rs. 1,500/- PG Student Rs. 500/- Rs. 750/- Catergory : Delegate Upto 10/04/2015 Accompanying Person From 11/04/2015 & Spot PG Student All payments by Demand Draft / Cheque in favour of Trivandrum Liver Clinics, Payable at Trivandrm Cheque/ Draft No : .......................Date ...................Rs...................................................... .. ................................................................... Bank............................................................... Send the duly filled registration forms along with DD/cheque to the conference secretariat Postgraduate students should submit a bonafide certificate from Head of the department / Institution. Please add out station fee of Rs. 40/Date : Accommodation at Venue Check in 18th April Check out 19th April Tariff Rs. 3750/- per room per night on single /double occupancy ba sis/ complementary breakfast. Signature Conference Secretariat Department of Medical Gastroenterology Super Speciality Block, Medical College Thiruvananthapuram-695011 gastrotmc@yahoo.com | www.gastrotmc.org Ph : 0471 2528783 ISG Kerala Chapter Annual Conference 2015 Workshop on EUS April 18th Venue : Endoscopy Suite, Super Speciality Block, Medical College, Trivandrum Kerala Chapter Registration Form Name : ............................................................................................................... Address : ............................................................................................................... ............................................................................................................... ............................................................................................................... ..............................................................Pincode.................................... Email : ............................................................................................................... Land Phone : ...................................................Mob :.................................................. Registration Fee : Rs. 500/All payments by Demand Draft / Cheque in favour of Trivandrum Liver Clinics, Payable at Trivandrum. Prior registration is mandatory : Registration restricted to 50 delegates on a first come first serve basis. Cheque/ Draft No : .......................Date ...................Rs...................................................... .. ................................................................... Bank............................................................... Send the duly filled registration forms along with DD/cheque to the conference secretariat Postgraduate students should submit a bonafide certificate from Head of the department / Institution. Please add out station fee of Rs. 40/Date Signature Conference Secretariat Department of Medical Gastroenterology Super Speciality Block, Medical College Thiruvananthapuram-695011 gastrotmc@yahoo.com | www.gastrotmc.org Ph : 0471 2528783
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