OFC Indian Dental Achievers Awards IDAA-2014 7:00PM Onwards on 2nd August 2014 at Indore. REGISTRATION FORM 1. NAME: ___________________________AGE/SEX: __________________ 2. DCI REGISTRATION NO :______________________________________ 3. QUALIFICATION(S): __________________________________________ 4. ADDRESS:___________________________________________________ _______________________________________________________________ 5. CITY:________________PINCODE:____________STATE_____________ 6. CONTACT No :_________________________________________________ 7. EMAIL ID :_____________________________________________________ 8. Kindly Attach a Brief CV including Academic Posts, Paper Publications, Book Contributions, Academic and Non Scholastic Achievements, Fellowships, Trainings, Awards, Inventions, Patents etc) 9. How do you consider yourself to be fit for ______________Category? (Enumerate in 50-75 words)……………………………………………………… Award Category: o JUNIOR o SENIOR (Kindly Tick mark the Relevant Category) Send us the above details at: [email protected] Or Courier it to: Editorial Office, OFC, India, H-11,1st Floor, Nishat Enclave, 74 Bungalows, Bhopal-462003(M.P),India For Further Enquires Contact: 09303917171,09826441255 AMOUNT TO BE PAID IN INR: ______________________ SIGNATURE MODE OF PAYEMNT 1. Cheque / DD favoring “Orofacial Chronicle” Payable at Bhopal. (For Outstation Cheque add Rs. 50/-) Cheque / DD No. ____________________ Dated________________________________ (Bank) _____________________ 2. Wire Transfer (Please send scanned copy of Deposit Slip at our Email) Bank Name: Bank of India Account Name: Orofacial Chronicle Account Number: 903720110000259 Branch Name: Nehru Nagar, Bhopal, M.P IFSC Code: BKID0009037 For Further Details Contact us at: [email protected]
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