_____________________________________________________________________ URPS 2015 Registration form - workshop / URPSSI membership ( Please use capital letters to fill up the form ) Title : ....................... Name : ................................................................................................................ Address for Communication : ............................................................................ ........................................................................................................................... City: ............................................ Pin Code:...................................................... State: ............................................ Country: ....................................................... Telephone (with area code) Res:..................................Off: ................................ Mobile: ............................................. Email :..................................................... Demand draft drawn in favour of “URPS 2015” payable at Chennai . DD :........................Dated :.......................Bank Details :............................................. Please  the category Consultants Postgraduates  Rs. 8,500  Rs. 5,000 Registration & URPSSI membership (21.12.2014 to 31-12.2014) already member  Rs.10,500  Rs. 7,000 Registration for non URPSSI members (< 20.12.2014)  Rs.10,500  Rs. 5,000 Registration for non URPSSI members (21.12.2014 to 31-12.2014)  Rs.12,500  Rs. 7,000 Consultants wishing URPSSI membership & Registration (< 20.12.2014)  Rs.9,500  Rs. 5,000 Consultants wishing URPSSI membership & Registration (21.12.2014 to 31-12.2014)  Rs.11,500  Rs. 5,000 Registration & URPSSI membership (< 20.12.2014) already member Address for Communication "URPSSI" No. 18/86, C. P. Ramaswamy Road, Abhiramapuram, Chennai – 600018, Tamilnadu, India, Email : [email protected] 1