NIC KOCHI 2014 Registration

MIDTERM MEET 2014

Cardiological Society of India

25-27 April 2014, Kochi

National Interventional Council

Registration
Tick Appropriate Category Upto 20thApril 2014

CSI No /
Course Name

Spot Registration

CSI Life Members*

Free

Free

PG Students

Free

Free

Non-CSI Members

Rs: 10,000/-

Rs: 12,000/-

Technologists/Nurses

Rs: 5,000/-

Rs: 8,000/-

Industry

Rs: 12,000/-

Rs: 15,000/-

DM

DNB

Hospital Name

Others

NA

NA

*CSI Life Members must provide their membership numbers
** The payment should be sent by Cheque or Demand Draft in favor of “Organising Secretary,National Interventional Council
Midterm Meet 2014” . For online payment log on to www.nickochi2014.org
*** Housing - Can only be done online. Log on to www.nickochi2014.org
MM
Title Prof.

Dr.

Mr.

Mrs.

Male

Female

DD

YYYY

Age ...................DOB

Name (in BLOCK Letters):.............................................................................................................................................................................
Address: ..........................................................................................................................................................................................................
........................................................................................................................................................................................................................
City:.............................................................................................................................Pin:..............................................................................
State:...........................................................................................................................Country:.......................................................................
Telephone(O): STD Code...........................No:.......................................(R) STD Code..........................No:.................................................
Mobile:.........................................................................................................................................Fax:.............................................................
E-mail:..............................................................................................................................................................................................................
Choice of Food Veg

Non Veg

Jain

Cheque/Demand Draft No:.................................................................................................................................Date:....................................
Bank:....................................................................................................Total Amount Rs:...............................................................................
Date:...........................................................................Signature:.....................................................................................................................

The registration form duly signed should be sent to the Conference Secretariat
Dr. Jabir A , Organising Secretary, NIC Kochi 2012
Lisie Heart Institute, Lisie Hospital, Kochi- 682 018, E-mal: [email protected],
Mobile: +91 95676 93154.
For office use only
Registration No:..............................................................................................................Date:........................................................................