CENTRE FOR CORPORATE GOVERNANCE, RESEARCH & TRAINING (CCGRT) Registration Form The Program CoCo-ordinator ICSI-CCGRT, Plot No. 101, Sector 15, Institutional Area, CBD Belapur, Navi Mumbai – 400 614 Dear Sir Please register me for the Workshop on “Corporate Governance and Board Leadership for Women Directors” Directors” scheduled to be held from Thursday, February 05 to Saturday 07, 2015 at Indian Merchants Chamber, IMC Building, 2nd Floor, Conference Hall, Indian Merchant Chamber Marg, Churchgate, Mumbai - 400 002. 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 : ` 20,000/- per participant For Registration: Registration The Fees may be drawn by way of D.D / local cheque payable at Mumbai in favour of “ICSI“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. ℡022-41021534, 022–2757 7814, 022 - 41021515, Fax–022–27574384, email: ccgrt@icsi.edu