th 6 Biennial Conference of the Indian Society for Study of Lung Cancer NALCCON 2015 18th-19th April 2015, Kolkata Registration Form Date : ____________________ Title: Dr / Prof / Mr / Mrs / Ms Name : ___________________________________________________________________________________________________ ( As it should appear on your badge and certificate ) Age : __________________ Sex : Male Female Specialty : _____________________________________ Designation : ____________________________________________ Organization :____________________________________________________________________________________________ Address : ________________________________________________________________________________________________ __________________________________________________________________________________________________________ City : _______________________________ Pin : _____________________ State : ____________________________________ Mobile (mandatory) : _____________________________ Email (mandatory) : ____________________________________ Associate Delegates : 1. __________________________________________________________________________________ 2. __________________________________________________________________________________ Registration Fee for the conference : ( [ ] Your appropriate Category ) Up to 28th Feb.2015 28th Feb.2015 Onwards Delegates INR 3000/- INR 4000/- PG Students INR 2000/- INR 2500/- Associate Delegates INR 2500/- INR 3000/- Payment Particulars: Enclosed, please find crossed Cheque / DD in favor of “______________”for Rs.___________ Drawn on ______________ Bearing No. _________ Dated _______________ Payable at Kolkata towards registration fee. Note : Please send the ﬁlled form along with Cheque / DD, to the conference secretariat address given below. Please mention your Name, City and Mobile No. on the backside of Cheque / DD. Conﬁrmation e-mail will be sent after realization of the Cheque / DD. The ofﬁcial receipt of the registration will be handed over to you at the registration desk during the conference. Conference Secretariat : Mr. Rajesh Sharma : +91 9374073521 Nucleus, A-1107 Siddhi Vinayak Tower, Nr. DAV International School, Makarba, Off SG Highway, Ahmedabad-380051. Contact Us: DR. GS BHATTACHARYYA Organizing Chairman Mb:9831011517 E : [email protected] DR. RAJA DHAR Organizing Secretary Mb: 9831855512 E : [email protected] For More information please visit www.nalccon2015.in or mail us on [email protected]