Pharmacist

for Better
Healthcare

REGISTRATION FORM
(PLEASE MAKE ALL ENTRIES IN BLOCK LETTERS)

Title Prof Dr Mr Ms Mrs

PHOTO
Name

Date of birth d d - m m - y y y y

Designation Organization
Correspondence Address:

City: State: Pin Code:

Phone with STD code - Res
Fax - Mobile
E-mail
Member of Professional Association: Yes No If Yes, Please give details :
Association IPGA AIDCOC IPA APTI IHPA Others
Membership No.

Area of Specialization Education Industry Research Regulatory Community Hospital Others

Accompanying persons
Name Name Name

Age (Yrs) Amount (INR/USD) Age (Yrs) Amount (INR/USD) Age (Yrs) Amount (INR/USD)

Choice of Food Veg Non-Veg

Registration Amount Payable Delegate - INR/USD: +Acc. Person - INR/USD: =Total INR/USD:

Remittance Details: Registration fee is not refundable and not transferable.

Find enclosed D.D./Pay Order No. Dated d d - m m - 2 0 1 0

Bank in favour of “62nd IPC A/c IHPA” payable at Manipal/Udupi

Amount in Rs. / USD (in words)

INR / USD Dated d d - m m - 2 0 1 0 Signature

• Photocopies of this form may be used • Students must enclose bonafide certificate from the head of the institution
Only registered delegates would be allowed to attend the conference.

Please carry your valid Photo Identity Card along with you for security reasons.
Please send the form along with all enclosures to:
Secretariat Office
Chief Coordinator, 62nd Indian Pharmaceutical Congress 2010
Manipal College of Pharmaceutical Sciences, Manipal University, Madhav Nagar, Manipal 576104, Karnataka, INDIA.
Phone: +91 820 2922433, 2922626; Fax: +91 820 2571998; Email: ipc2010@manipal.edu Website: www.ipc2010manipal.org

For online Registration visit us at www.ipc2010manipal.org