REGISTRATION FORM
Course on
Liver Transplant Anesthesia and Intensive care
November 5-6, 2011 | Medanta-The Medicity, Gurgaon
In association with Indian College of Anaesthesiologists &
Indian Society of Anaesthesiologists
(Please use CAPITAL LETTERS)
Name: Prof. / Dr. / Mr. / Mrs. / Ms.
________________________________________________________________________________
(As required on Badge)
Address: ____________________________________________________________________________________________________________
Institute: ____________________________________________________________________________________________________________
City/ State: ____________________ Postal Code: ______________________ Telephone: __________________________________
Mobile: _________________________________ E-mail: ___________________________________________________________________
Registration Fee
Rs. 2500 (National)
USD 100 (Overseas)
Payment Details
Payments should be made by demand draft / cheque payable at par in favour of "Global Health Pvt. Ltd.”
payable at New Delhi.
Bank Transfer Details:
Bank Name
: YES BANK LTD
Branch Address
: 48, Nyaya Marg, Chanakyapuri, New Delhi 110021
Current Account No. : 00380200000292
IFS Code
: YESB0000003
Beneficiary Name
: GLOBAL HEALTH PVT LTD
Please find enclosed cheque / demand draft no. _____________ dated _____________ amount________________
bank & branch name _____________________________________________________________________________________________
OR
Please note the transaction ID ________________________________ of the Amount Rs _____________
Dated __________________ deposited in YES Bank account No. 00380200000292 (Course on Liver
Transplant Anesthesia and Intensive Care) Medanta - The Medicity, Gurgaon.
Signature____________________________
Please mail this registration form duly filled to:
Conference Secretariat:
Neumech Events: 908 Chiranjiv Tower, 43 Nehru Place, New Delhi 110019
Ph: + 91 124 4855 222, Mobile: +91 9717298180 / 9717298178
For additional information regarding your registration please send an
email: caltmedanta@gmail.com website: http://www.medanta.org/calt/index.html