THANJAVUR TLIF COURSE AND BASIC SPINE CADAVERIC

WORKSHOP

REGISTRATION FORM

NAME:…DR.SYED BAKHAR M.S ORTHO…………… DOB:………24.06.1984………………………………

(PLEASE FILL IN CAPITAL LETTERS AS TO BE APPEAR IN THE CERTIFICATE)

DESIGNATION: -ASSISTANT SURGEON------------------------------------------ DEPARTMENT------ORTHO

--------------------

HOSPITAL/INSTITUTION: -GOVT.HEAD QUARTERS HOSPITAL, MANAPPARAI----------------------------- MAILING

ADDRESS: Govt.Hospital Manapparai

MOBILE: 9842345551 E MAIL: drbakharortho@gmail.com ----------------------------------------

MEDICAL COUNCIL NUMBER: -86303-- TNOA REG NO: ---------------- ASSOCIATE/ LIFETIME MEMBER

STATE: --------TamilNadu----------------------

REGISTRATION CATEGORY: PG STUDENT CONSULTANT

PREFERENCE OF MEALS: VEG / NON VEG

PAYMENT DETAILS:

DEMAND DRAFT CASH IMPS/NEFT. YONO SBI APP

DD NO: ---------------DATE: --------------DRAWN ON BANK: --------------------- BRANCH: ----------------------

IMPS / NEFT TRANSACTION NO: -----------------------------------------

DATE: -------5.03.2020------------ SIGNATURE:

------------------------

REGISTRATION TARIFF IN RUPEES INCLUSIVE OF GST

CATEGORY AMOUNT

CADAVERIC WORKSHOP PAYMENT DETAILS:

Rs.5000/-
NOTE: CANCELLATION CHARGES WILL BE APPLICABLE AS PER Account name : ORTHOCME AND WORKSHOP
THE POLICY
Account No : 38487175124
MODE OF PAYMENTDD TO BE DRAWN IN FAVOUR OF Bank : State Bank of India.
“ORTHOCME WORKSHOP” PAYABLE AT THANJAVUR.
Thanjavur Medical College Campus

IFSC code : SBIN0007880

PLEASE SUBMIT THE DUTY FILLED FORM AND PAYMENT TO DR.S.SIVABHARATHI

E MAIL: tmch2015@gmail.com/ CELL: 9159998011