2 nd PAi Conference & International Symposium New Delhi- 3 rd to 4 th November, 2014 Registration Form Please fill in block letters Dr. /Mr. /Mrs................................................................................................................................................................... Accompanying Person.................................................................................................................................................... Age..................... Sex- M/F Designation.................................................................................................................... Mailing Address.............................................................................................................................................................. ..........................................................City..........................................................Pin Code............................................... State.........................................Country…...........................................Tel...................................................................... Mobile........................................................E-mail.......................................................................................................... DELEGATE CATEGORY PAi Member Non PAi Member Foreign Delegate PAYMENT DETAILS (Tick Wherever Applicable) st th Early Bird(Before 31 July) Before 15 October 1.Registered Member : Rs. 4000 Rs. 5000 2.Non Registered Member : Rs. 5000 Rs. 6000 3. Registered Student Member : Rs. 2000 Rs. 2500 4.Non Registered Student Member : Rs. 2500 Rs. 3000 5.Corporate Member Free Registration for three participants from industry For additional participants : Rs. 5000 Rs. 6000 6. Non Registered Industry : Rs. 7500 Rs. 8500 7.Foreign delegates : US $ 600 US $ 800 On Spot Registration Rs. 10000 (Students to send a Xerox/Scanned Copy of their current college Identity card for verification) DD No............................................Dated.....................................Drawn on.................................................................... For Rs:.................................... (Rupees....................................................................................................) in Favour of “Probiotic Association of India” payable at Karnal. Payment by cheque can also be made at any branch of State Bank of Patiala in favour of “Probiotic Association of India” A/C No. 65099793148, State Bank of Patiala, NDRI, Karnal Payment deposited in SBOP branch……………………....Dated………………Amount Rs…………......................... Please attach photocopy of Pay in Slip (Deposit Slip) with registration form. Payment by electronic transfer can also be made from your account in favor of “Probiotic Association of India” A/C No.65099793148, State Bank of Patiala, NDRI, Karnal. For e-banking IFSC Code- STBP0000326, A/C No. 65099793148 NOTE: While doing internet bank transfer (NEFT). Inform us your payment confirmation details by fax / email For Office Use Only: Receipt No.: …………………………… Registration No.: ……………………………………… Transaction ID……………………Transaction Date…………..…Transaction Amount…………………………… Please send duly filled registration form along with DD / Cheque to our official Event Manager: Dreamz Conference Management Pvt.Ltd. \218, Ansal’s Majestic Tower, Vikas Puri New Delhi – 110018 Tel: +91 11 41586401 Fax: +91 11 41586400 Email: [email protected] , [email protected]