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Participant Online Registration Cum Payment Form

Registration Type *

Individual Corporate

First Name *

Last Name

Organization *

City *

State

Country *

Pin Code

Phone *

Fax

Email *

Comments

Accommodation Required

Yes No

Payment Amount

Up to 15/10/2006   Rs 2,000   Individual
Up to 15/10/2006   Rs 7,500   Corporate
From 16/10/2006    Rs 2,500   Individual
From 16/10/2006    Rs 7,500   Corporate
Overseas               400 US$   Individual
Overseas               1000 US$ Corporate

Make Payment

Demand Draft Credit Card

Demand Draft-Details

Drawn In Favour Of *
MEDICAL INFORMATICS 2006

Payable At *
Kochi

DD Number *

Name Of The Bank *

Name of The Branch *

Date Drawn *

Credit Card-Details

Name *
(As appearing on your Card)

Credit Card *

Card Number *

Date of Expiry *

* Fields are Mandatory

Please send your registration fee by credit card or demand draft as soon as possible
to avail of the early registration discount.
Registrations can be confirmed only after receipt of payment.

Registration Charges
India & S A A R C Countries
	Individuals	Corporate ( For Three Members)
Up to 15/10/2006	Rs.2,000	Rs 7,500
From 16/10/2006	Rs.2,500	Rs 7,500

Overseas	US$ 400	US$ 1000
Note : Members of MCSI can avail a discount of 15% on registration fees.
Sponsorship / Advt. Charges
Chief Event Sponsor		Rs. 5 Lakhs or US$ 11,000 (Gold Sponsor)
Conference Co-Sponsors (Three)		Rs. 2 Lakhs or US$ 4,500 (Silver Sponsors)
Session Sponsors		Rs. 1 Lakh or US$ 2,200

Sponsoring Conference / Kits		As per actual expenses
Dinner & Entertainment Night		As per actual expenses
Sponsoring Lunch		As per actual expenses
Sponsoring National / International Speaker		As per actual expenses
Please Note : For details on charges, benefits and visibility for various type of sponsorships and Advertisements please contact the Conference Manager.

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