2019

3rd - 6th October, 2019

HICC, Hyderabad

27th Annual Conference of Indian Academy of Neurology

rd th
3 - 6 October, 2019 | HICC, Hyderabad
REGISTRATION FORM
PERSONAL DETAILS
(Please fill in CAPITAL LETTERS)
Prof. Dr. Mr. Ms. Mrs.
*First Name ________________________________________________ Last Name _____________________________________

Hospital / Institution __________________________________________________________________________________________

Designation _____________________________ Department ___________________________ Nationality _________________

Correspondence Address____________________________________________________________________________________

City_________________________ *Pin code_________________ State _____________________ Country _________________

Phone __________________________________________________ *Mobile _________________________________ ___________

Email __________________________________________________ IAN Membership No. __________________________________

*(Mandatory)
Registration

Upto Upto Upto Upto Spot

Category st th st st
31 Jan 2019 30 Apr 2019 31 Jul 2019 1 Sep 2019 Registration
Member INR 5,500 INR 9,300 INR 15,400 INR 16,900 INR 18,900
Non Member INR 11,500 INR 16,100 INR 23,700 INR 27,900 INR 31,400
Accompanying Person INR 4,100 INR 6,200 INR 8,400 INR 16,100 INR 17,700
Students / Residents INR 2,400 INR 3,100 INR 4,700 INR 6,200 INR 11,800

Accompanying Person Name ___________________________________________________________________________________

Age ____________________________________________ Gender _____________________________________________________
Cheque /Demand Draft for the appropriate amount to be raised in favour of “IANCON 2019”

Amount (in figures) _______________________ (in words) ____________________________________________________________

Cheque / Demand Draft No. _____________________ Dated ________________ Drawn on Bank_____________________________

Bank Account Details

Account Name: IANCON 2019 U/O BASS Account Type: Savings Account
Bank Name: HDFC Bank IFSC Code: HDFC0000317
Account No.: 50100264158977 Branch Code: 0317

Organising Secretary Conference Manager

years

2019
3rd - 6th October, 2019
HICC, Hyderabad CIMGlobal India Pvt Ltd
Dr. Sita Jayalakshmi Plot No 12, Doctors Colony, Vasantha Emerald Gardens,
Department of Neurology, 3rd Floor, Madhapur, Hyderabad-500 081
KIMS Hospital, Secunderabad – 500003 Mr. Kiran Kumar Lella
Email: info@iancon2019.com M: +91 - 80198 02997 | E: Kiran@cimglobal.net

www.iancon2019.com