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FORM
'A'
ISG2001 REGISTRATION FORM
(For Pre-CME workshops, CME, Conference, Endoscopy workshop, Crohn's
disease symposium,
Meet-the-Professor sessions. Please use capital letters.)
Name: First ……………………………….
Middle ………….……… Surname …………………………
Mailing address……………………………………………………………………………………………..
………………………………………………………………………………………………………………
City……………….……………………
Pin……………………………………
State……………………………………
Country……………………………….
Telephone………………………………
Fax……………………………………
Email……………………………………………………………………………………………………....
Status: Member / Non-member / Trainee / Accompanying person / SAARC
/ Foreign (non-SAARC)
delegate
Accompanying person(s)
Name…………………………………………………….……………….Age…….……
Sex…………...
Name………………………………………………….………………….Age………….
Sex…….……..
Name…………………………………………………….……………….Age……….…
Sex……….…..
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Details
of registration and registration fees
|
Tick
if applicable
|
Amount
|
| Scientific
Communication Workshop |
[
]
|
Rs./USD
_______
|
| GI
motility Workshop |
[
]
|
Rs./USD
_______
|
| Continuing
Medical Education |
[
]
|
Rs./USD
_______
|
| Conference |
[
]
|
Rs./USD
_______
|
| Endoscopy
workshop |
[
]
|
Rs./USD
_______
|
| Accompanying
person(s) [Number ______ ] |
[
]
|
Rs./USD
_______
|
| Interested
in Meet-the-professor session(s)* |
[
]
|
|
| Will
attend 'Crohn's disease symposium' |
[
]
|
No
Fees
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| Total
amount |
[
]
|
Rs./USD
_______
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Payment Details
Bank draft No. ………………… Date ………………. Amount Rs./ US$ …….…….. in favour of ISG2001,
drawn on ………………………………………………………………. (bank & branch), payable at Lucknow.
Please send the
completed form along with bank draft to:
Dr. G Choudhuri
Joint Organizing Secretary
Department of Gastroenterology
SGPGI, Lucknow 226014, India
Ph. +91-522-440700 extn 2400, 2428 Fax: +91-522-440017
Email: isg2001@sgpgi.ac.in,
gc@sgpgi.ac.in Website: www.sgpgi.ac.in/conf/isg2001.html
* More details of
these sessions will be sent to those who indicate interest. Please do
not send payment
for this till your participation in these sessions has been confirmed
by the Organizing Committee.
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