Registration Form

ESI Member Non-Member P.G. Student
 
Surname _____________________
First Name _____________________
Institution / Company _____________________
Department _____________________
Address _____________________

_____________________

_____________________

_____________________

City _____________________
Pincode _____________________
Country _____________________
Tel _____________________
Fax _____________________
Email _____________________

Last date for Early Registration : 30th September, 2001

Cheque / Demand draft / Payorder in favour of "ESICON 2001" payable at Mumbai. (Add Rs. 50/- for outstation cheques)
Please mention :
Demand draft number ______________________
Amount ______________________
Date ______________________
Drawn on ______________________   Bank
Accompanying person ______________________
Surname ______________________
Name ______________________
Please mail to:
Dr. Nalini Shah
Secretariat
31st National Conference of the Endocrine Society.
Dept. of Endocrinology, K.E.M. Hospital, Parel, Mumbai 400 012.
Tel: 91-22-416 8714
Fax: 91-22-414 3435
Email: kemendo@vsnl.net
REGISTRATION INFORMATION
All delegates including faculty and members of the organising committee are requested to register ahead of the deadline. Request for cancellation of registration fee will be accepted till November 15th, 2001. Spot registration will be made on receipt of cash only. Credit cards, travellers cheques or personal cheques will be not be accepted at the registration counter.
For additional registration form xerox copies can be used.

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