17

th

IPS Post Graduate Convention

VSPM Dental College & Research Centre, Hingna, Nagpur (M.S.)

10

th

th

-12 July 2015 ( www.17thipspgcon.com)

Photo

Prosthodontics: Basics to Beyond

Registration no.(For Office use only)

Registration Form
IPS Membership No.
Personal Details (Please fill in capital letters only)
Name:
College Name:
State:
City:
Correspondence Address:
Designation:
Mobile No.
E-mail:
Category:
Accompanying Person:

Date:

Pin Code:

Registration Fees:Category
st

From November 2014 till 31

st

From 1 April 2015 till 30

st

Spot Registration 1
Non-IPS member
Bank Details:

th

March 2015

June 2015

July 2015 onwards

Delegates

Students

Accompanying Person

INR 4000/-

INR 4000/-

INR 4000/-

INR 5000/-

INR 5000/-

INR 5000/-

INR 5500/-

INR 5500/-

INR 5500/-

INR 5500/-

INR 5500/-

INR 5500/-

Axis Bank,
Account No. 914010040149221
IFSC Code: UTIB0001242
Account Name: 17 TH IPS PG CONVENTION, Nagpur.
(DD should be drawn in favour of account name)

Payment Details: Cash / Demand Draft No. / NEFT Reference No. :_____________

For Registration Contact: Dr. Neelam Pande: +91-9822931899, Dr. Anita Kahar: +91-9421805735
E-mail: pgcon2015reg@gmail.com

Duly filled Registration Form along with DD / Online Transfer Receipt to be sent to the Conference Secretariat, by
Registered Post / Courier.
Your registration will only be confirmed on the receipt of the Registration Form and the proof of payment.
PG student should attach a letter from HOD as a proof of belonging to that College / University.
Spot registration does not include gift.
Accompanying person registration includes lunch, dinner, banquet and entry to scientific sessions and trade.

Address: Conference Secretariat, Dr. Sham Gundawar (Organizing Secretary)

Dept. Of Prosthodontics, VSPM Dental College & Research Centre, Digdoh Hills, Hingna Road, Nagpur-440019
M. +91-9822361524 Fax: (07104)232904