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  • CCRC Registration Form

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    aveekumbhar
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    The document is a registration form for a 5th Annual Critical Care Refresher Course held from February 15-18, 2017 in Delhi and NCR, India. It requests the name, designation, institute/hospital, address, phone number, and email of the registrant. The registration fee is Rs. 5000 and can be paid via demand draft, cheque, or online. The form provides contact information for Dr. Mozammil Shafi to submit registrations.

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    The document is a registration form for a 5th Annual Critical Care Refresher Course held from February 15-18, 2017 in Delhi and NCR, India. It requests the name, designation, institute/hospital, address, phone number, and email of the registrant. The registration fee is Rs. 5000 and can be paid via demand draft, cheque, or online. The form provides contact information for Dr. Mozammil Shafi to submit registrations.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    48 views1 page

    CCRC Registration Form

    Uploaded by

    aveekumbhar
    The document is a registration form for a 5th Annual Critical Care Refresher Course held from February 15-18, 2017 in Delhi and NCR, India. It requests the name, designation, institute/hospital, address, phone number, and email of the registrant. The registration fee is Rs. 5000 and can be paid via demand draft, cheque, or online. The form provides contact information for Dr. Mozammil Shafi to submit registrations.

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    © All Rights Reserved
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    ISCCM Delhi & NCR

    REGISTRATION FORM

    5TH ANNUAL CRITICAL CARE REFRESHER COURSE

    15th, 16th, 17th & 18th February, 2017 (Wed, Thu, Fri & Sat)

    Name ..................................................................................................................

    Designation ........................................................................................................

    Institute / Hospital ................................................................................................

    Address ...............................................................................................................

    ............................................................................................................................

    City ................................................. Pin Code .....................................................

    Phone: (Mob)................................... (R.) .............................................................

    Email: ..................................................................................................................

    Registration Fee Rs. 5000/-

    Mode of payment: DD Cheque Online

    DD/ Cheque No: ................ Dated: .............................. Drawn on ......................

    DD/Cheque to be drawn in favour of Society of Critical Care Medicine Delhi and


    mailed to the address below.

    For online payment kindly visit www.isccmdelhi.com

    For registrations kindly contact:


    Dr Mozammil Shafi
    Liver Transplant & Gastro ICU
    ICU 9 & 10, 2nd Floor
    Medanta The Medicity
    Sector- 38, Gurgaon
    Haryana 122001
    Ph: +919599557808
    Email: intensivecarecme@gmail.com

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