Registration Form
Personal Details
Title*
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Dr.
Mr.
Mrs.
Ms.
Prof.
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First Name*
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Last Name
Contact Details
Affiliation/Institute*
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Designation
Email*
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Phone*
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Mobile
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Fax No.
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Address*
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City
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State*
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Pincode*
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Country*
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Afghanistan
Argentina
Australia
Austria
Bangladesh
Belgium
Bhutan
Brazil
Bulgaria
Burma
Cambodia
Canada
Chile
China
Colombia
Cuba
Denmark
Egypt
Ethiopia
Fiji
Finland
France
Germany
Greece
Greenland
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Korea
Kosovo
Kuwait
Lebanon
Liberia
Libya
Malaysia
Maldives
Mexico
Nepal
Netherlands
New Zealand
Nigeria
North Korea
Norway
Pakistan
Peru
Philippines
Poland
Russia
Serbia
Singapore
South Africa
South Korea
Spain
Sri Lanka
Switzerland
Thailand
Turkey
United Kingdom
USA
Zambia
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Passport Details
Passport Number*
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Place of Issue*
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Date of Issue*
(mm/dd/yyyy)
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Date of Expiry*
(mm/dd/yyyy)
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Category Description (Spot Registration)
INR 3,000
INR 4,000
INR 2,500
INR 1,500
USD 300
Applicable Conversion Rate to INR (1 USD = 50.00 INR)
Accompanying Person Details
Accompanying Person
Name*
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Amount Paid*
INR 2,000 (per person)
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Payment Details
Demand Draft No.*
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Name of the Bank*
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Note
:-
The Draft will be in favour of "IAPCON-2009" and send it to:-
Dr. Sushma Bhatnagar
Organizing Secretary
Room No. 242, Unit of Anesthesiology
Dr. B.R. Ambedkar Institute Rotary Cancer Hospital,
AIIMS, New Delhi-110029, India