CENTRE FOR CORPORATE GOVERNANCE, RESEARCH & TRAINING (CCGRT) Registration Form The Program Co-ordinator ICSI-CCGRT, Plot No. 101, Sector 15, Institutional Area, CBD Belapur, Navi Mumbai – 400 614 Dear Sir Please register me for the Full day Program on “Posers on Companies Act 2013” scheduled to be held on Friday, November 21, 2014 at ICSI-CCGRT, Plot No 101, Sector 15, Institutional Area, CBD Belapur, Navi Mumbai – 400 614. Participant Details (in BLOCK LETTERS) Name & Designation: ….….………………………………………………………………………………………………… ACS / FCS No …….……………………… or Student Registration No.…..…………................................... Company/Bank/Institution:….………………………………………………………………..…….………………….. Address: …………………..…………………………………………………………………………………..………………… ………………………………………………………………………………………………………………………………………… Telephone: Off: …………………………. Res : …………………….. Fax …………………….………………………. Email: ………………………………………………….. Mobile: ……………………………………………………………. Cheque / DD / NEFT Reference No: ………………………..................................................................... Fees : Members Students Others ` 1,600/- per Member ` 1,200/- per participant ` 2,000/- per participant For Registration: The Fees may be drawn by way of D.D / local cheque payable at Mumbai in favour of “ICSI-CCGRT A/c” and sent to Shri Gopal Chalam, Dean, ICSI-CCGRT, Plot No. 101, Sector -15, Institutional Area, CBD Belapur, Navi Mumbai – 400 614. 022-27577814, 022-41021515 / 33 , Fax: 022-27574384, email: ccgrt@icsi.edu