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First Name
57thAICO
Innovation to Implementation
Patna
2014
Organised by:
Middle Name
Last Name
Name* Designation Institute Address City State Telephone E-mail# Accompanying Persons 1 2
#
Sex
Age
Payment Details (Tick whichever is applicable. The Amount is inclusive of all Applicable taxes) Registration Fees
Workshop
CME FOGSI Member Non-FOGSI Member P .G. Students* Accompanying Person Banquet Fees Foreign Delegate
21st Jan13 to 30th Sep13 ` 3596 ` 1686 ` 7304 ` 8427 ` 4495 ` 6742 X ` 2809 X ` 16854
Total
Meal Preference
Veg
Non-Veg
Jain
Children below 7 Year, if any (no fees applicable) Name 1............................................................ 2............................................................ Age .......... ..........
Signature..........
Date..............
Please turn overleaf for Registration Guidelines
Registration Form
57thAICO
Innovation to Implementation
Patna
Please complete and return at your earliest convenience to: Congress Secretariat 57th AICOG 2014 Gynae Wing, IMA Building Dr A K N Sinha Path, Patna - 800004, Bihar
Registration Guidelines
The registration categories and fees are listed in the registration form. The duly competed form with the payment
Phone:+91 0612 2321542 Moblie: +91 8002634964 Email: secretariat@aicog2014patna.com Website: www.aicog2014patna.com
should reach the conference secretariat at the address given in the registration form.
Congress registration is mandatory for registration in workshop & CME Registration will be valid only on the date of receipt of payment instrument. Registration fees will be calculated as
Overseas Delegates
Delegates from other countries need to be registered as per the registration details
Accompanying Delegates Activities for accompanying delegates will be organised at the conference venue. Accompanying delegates will not be allowed in the scientific halls Mode of Payment
Online Credit Card Payment: visit www.aicog2014patna.com Offline Payment: You can make your registration payment through Demand Draft for the appropriate amount in
favor of 57th AICOG 2014, Patna payable at Patna, Bihar. You can also pay the registration payment through Bank Transfer. The details are Bank Name : Canara Bank Branch: Patna South Gandhi Maidan (352) Ac Name: 57th AICOG 2014 Ac/No: 0352101041251 IFSC Code: CNRB0000352 The Conference organizers are not responsible for postal delays/failure of delivery by post or failure of electronic communication. Please keep the confirmation letters along with the registration details safe and produce them at the registration counter while checking in the conference venue. This is COMPULSORY Refund Policy
Email received for cancellation/refund will have to be supported by subsequent formal written letter. Those who have
intimated their non-participation in writing to the conference secretariat will only be considered for refund as applicable on the date of receipt of the intimation of non-participation. Refund will be made only after the conference. Refund will be paid by cheque only. 75% of total registration fees will be refunded if the cancellation request is received before 15th October, 2013. No refund after 15th October, 2013
Official Event and Travel Managers Thomas Cook (India) Ltd / Travel Corporation (India) Ltd, Plot No. 520, Udyog Vihar, Phase - III, Gurgaon 800 001, Haryana P: +91 124 6120263 | F: +91 124 6120282 | Email: secretariat@aicog2014patna.com | Website: www.tciconferences.com
2014
Organised by: