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GUJPEDICON 2021 Registration
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* Indicates required question
Name (in Full)
*
Your answer
MOBILE NUMBER
*
Your answer
E-mail
*
Your answer
POSTAL ADDRESS
Your answer
NAME OF THE INSTITUTE/ HOSPITAL
Your answer
CITY
Your answer
STATE
Your answer
IAP MEMBERSHIP NUMBER
Your answer
AOP, GUJARAT MEMBERSHIP NUMBER
Your answer
AOP Member/ SPACT Member
*
Yes
No
PG Student (Letter from HOD must)
Yes
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Accommodation
Charges: Rs. 2000 per person
On Twin sharing basis
For Single Night (18th Dec. 2021)
Check in Time 01:00 pm
Subject to availability
REGISTRATION TYPE
*
INDIVIDUAL
WITH ACCOMPANYING DELEGATE/ SPOUSE
ACCOMMODATION REQUIRED
*
Yes
No
MODE OF PAYMENT
*
CASH
CHEQUE (AT PAR MULTI-CITY) - In Favour of "GUJPEDICON 2021"
DEMAND DRAFT
ONLINE TRANSFER
Amount
*
Your answer
CHEQUE No. / DD No. / Reference No. (WITH BANK NAME)
*
Your answer
TRANSACTION DATE/ DATE OF CHEQUE
*
MM
/
DD
/
YYYY
Note
*
Column 1
Transaction details to be sent to Organizing Secretary, GUJPEDICON 2021 by Whatsapp/ email.
Column 1
Transaction details to be sent to Organizing Secretary, GUJPEDICON 2021 by Whatsapp/ email.
BANK DETAILS
ACCOUNT No.: 3877274064
ACCOUNT NAME: GUJPEDICON 2021
BANK NAME: CENTRAL BANK OF INDIA
BRANCH: ADAJAN (SURAT)
IFSC CODE: CBIN0283527
TYPE OF ACCOUNT: CURRENT
Contact Details
Dr. Manish Sharma
Organizing Secretary
GUJPEDICON 2021
98255 49694
secretariat.gujpedicon2021@gmail.com
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