CUTICON WB 2014 Registration Form Registration No______________ For Office use Only All in Capital letters except Email Bring Two (2) Printed Copies Paste Photo here IADVL No. __________ M Name (in full)_______________________________________________________________________Date Of Birth____________ Sex F Address______________________________________________________________________________________________________ ____________________________________________________________________________________________________________ State______________________________________________________________________________ Pin Code Phone (Res.) with STD Code _____________________________________________ Mobile +91 Veg Email ____________________________________________________________ (if not existing, Please create one) Upto 16.05.2014 (Friday) Category Upto 17.07.2014 (Thursday) Upto17.11.2014 (Monday) Food Selection Non Veg *18.11.14 Onwards (Tuesday) 1400/- 1800/- 2500/- 3500/- 1200/- 1500/- 2000/- 3000/- PGT 1200/- 1400/- 2000/- 3000/- Non IADVL Member 2500/- 2800/- 3000/- 3500/- Corporate Member 3000/- 3500/- 5000/- 6000/- Member Accom. person (s) Nos Total Rs. Total Rupees (in words) ________________________________________________________________________________________________ Cheque / D.D. No. ______________ Date _______________ Bank & Branch Name ________________________________________________ Post Graduate Students should submit a letter from HOD as a proof of belonging to that College / University. Non IADVL Member (Dermatologist) should submit copy of Updated Medical Council Registration Certificate. Payment with Cheque (At par for out-station) or Demand Draft should be made in favour of “CUTICON WB 2014” payable at Kolkata. *Payment on and from 18th November 2014 will be considered as Spot Registration and might not be entitled for any kit or other gifts. Date_______________ ____________________________ Signature Please note, the filled up form can only be submitted to : The Organising Secretary, CUTICON WB 2014, IADVL, WB State Branch Moon Plaza, Flat-2E, 2nd Floor, 62, Lenin Sarani, Kolkata - 700013, West Bengal Phone: +91 33 22277553, Email: [email protected], Website: www.iadvlwb.org 18th Annual State Conference of IADVL West Bengal State Branch
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