nurcon a cultural shift - moving towards new horizons th th 2015 REGISTRATION FORM Date: 17 - 18 October 2015 Personal Details: Name: Dr. /Mr. /Ms . ...................................................................................................................... Age: ........................... Years Sex: [ ] M [ ] F Designation: .................................................................................................................................... Name of the Hospital: ...................................................................................................................... Address: ......................................................................................................................................... ....................................................................................................................................................... Total Years of Experience: ................................................................................................................ Details of the Cheque: Amount: ................................................. Cheque Number: .............................................................. Name of the Bank: .................................................................. Branch: ............................................ Kindly make the cheque in favor of: “Dr. L. H. Hiranandani Hospital” Registration Fees: st Till 31 August, 2015 Early Bird PG Student (ﬁrst 30 registration) Spot Registration Free PG Students INR 1500 INR 2000 Staff Nurses INR 2000 INR 2500 Registration will be conﬁrmed upon realization of cheque. Kindly courier your ﬁlled form and cheque / pay order to: Ms. Valsa Thomas, Nursing Director, 1 Floor, Dr. L. H. Hiranandani Hospital, Hillside Avenue, Hiranandani Gardens, Powai, Mumbai - 400076 st Phone: 9769910169, 9769910185 Email: [email protected]; [email protected]