DEPARTMENT OF PLASTIC   SURGERY

Jawaharlal Institute of Postgraduate Medical Education and Research 

Pondicherry 605 006

 Home

Invitation

 Organising Committee

Registration

Accommodation

Programme

Faculty

General Info

 2^nd OPERATIVE WORKSHOP

ON

HYPOSPADIAS

REGISTRATION FORM

2^nd Operative Workshop on HYPOSPADIAS

 Department of Plastic Surgery, JIPMER,  Pondicherry

22 – 24^th August, 2008

REGISTRATION FEE

*With a certificate from HOD

Name: Dr/Mr/Ms…………………………………….  Surname: …………………

Designation(Postgraduate/Faculty)……………………….…………..

Speciality………………………………………………………………………

Institution……………………………………………………………………...

Address: ……………………………………………………………………..

………………………………………………………………………………………..

City: ……………………………… Pin …………….State: ……………………

Telephone (Office)………………………………(Res)……………………….

Mobile……………..………………..  Email…………………………………..

Accompanying Persons:

Name……………………………………………Age……………………Male/Female

Name……………………………………………Age……………………Male/Female

Name……………………………………………Age……………………Male/Female

Registration Fee Details:

a. Delegate Fee:                          Rs…………….          

b. Accompanying Person:            Rs…………….                  Total amount (a+b+c):  Rs…………

c. Advance for Accommodation: Rs……………..           

(Independent/ Shared with…………………………….…..preferred partner if any)               

Hotel: First preference…………………….Second preference………………………

Cash/ At par cheque/ Bank Draft Details:  No……………………dated………………….

For Rs…………………. Drawn on……………… ………………..Bank in favour of  “PLASTIC SURGERY WORKSHOP”, payable at Pondicherry.