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CONFERENCE REGISTRATION FORM
| Name | ||
| Qualification | ||
| Address for Correspondence | ||
| City / Town | ||
| Pin Code | ||
| Phone No. with STD code | ||
| Fax No. | ||
| IDA Membership No | (if unknown enclose photocopy or subscription receipt) | |
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PRE-CONFERENCE COURSE CHOICE |
A / B / C / D |
| Is Accommodation required for 14th December |
Yes / No (Full Payment required) |
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CONFERENCE |
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| Are you presenting a Scientific Paper |
Yes / No |
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Is Accommodation required for main conference 15th & 16th December |
Yes / No (Full payment required). |
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Give preference of accommodation, venue and type in the following order. |
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| Choice | |
| 1st Choice | |
| 2nd Choice | |
| 3rd Choice | |
| For double / triple sharing accommodation, give details of delegate with whom the room is to be shared | |
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FOR STUDENT CONVENTION |
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| Registration for Students Convention |
Scientific / Sports / Cultural (tick all applicable) |
| Is accommodation required for 14th Dec. |
Yes / No (full advance of Rs. 250/- required) |
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Students desirous of attending the main conference must register as Student Delegates for the same irrespective of their registration for the Student Convention |
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REMITTANCE DETAILS |
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| Registration fee for Students Convention | |
| Accommodation for Students Convention | |
| Accommodation for Pre Conference Course | |
| Conference Registration Fee | |
| Accompanying person | |
| Children under 12 years | |
| Accommodation for Main Conference dates | |
| Banquet | |
| Total | |
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I enclose a bank DD no. _____________ dated ___________ drawn on __________ |
| for Rs. ___________ in favor of "19th Tamil Nadu State Dental Conference, Chennai" |
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Date Signature |
