Registration Form

Dear Participant

PLEASE, before you submit this form look carefully at the details in Registration details.
Complete information will be helpful to the Symposium organizer. Many Thanks.

PLEASE fill in form in Block Letters.

Name *	:
Email *	:
Affiliation *	:
City *	:
Country *	:
Cell No *	:
Landline No *	:
Registration Types *	:	Select Academi PhD Student Industry/Others
Abstract Topic * (If participating)	:
Registration Fees (includes Kit, High Tea, Lunch)	:	Academia: ` 300/- PhD Student: `300/- Industry & others: `500/- Spot registration: `1000/-
	:

	DD/Cheque in favour of “Indian Burns Research Society- CME”
	Can be done by Direct Deposit/ Bank Transfer Details.

You can send DD/Cheque at:

Research Team
National Burns Centre
Sector-13, Plot no: 1, Airoli,
Navi-Mumbai-400708 (INDIA).

Bank Account Details:

Account Name	:	Indian Burns Research Society- CME
Bank Name	:	State Bank of India
Bank Address	:	Rabale Trans- Thane- Creek I A Thane Belapur Road, Vill -Airoli, Thane Dist Maharashtra- 400 708
Account No:	:	S. B. A/C: 10079313021
IFS Code NO	:	SBIN0003375
MICR Code No	:	400002098
Swift Code No (Foreign Transaction)	:	SBININBB236

Poster Size: upto maximum size of 120 cm height and 90 cm width is only allowed.

Last Date for DD/Cheque to reach us: 8 July, 2013.

Last Date for submitting Registration Forms: 8 July, 2013.

For Further Information & queries Contact:

Nigamananda Dey
Contact: 022-27796660-63
Email:    researchnbc@gmail.com