Registration Form

Name

Dr/Mr/Ms.

Age

Sex

Male / Female

Designation

2007 IBS Member

Yes / No       If Yes, Membership No.

Past IBS Member

Yes / No       If Yes, Membership No.

Abstract submitted

Yes / No

Organization

Address

Phone No:

Res:                                       Off:

Email ID

Wish to participate

            Workshop/CME   

             Conference     

Yes / No

Yes / No         

Registration Fees to be paid by Demand Draft in favor of “Organizing Secretary, IBS (IR) Conference” payable at Chennai.

DD No:                                      Bank:                                           Amount: Rs.

Workshop participants should also provide the following information:

Subject of the PG degree

Specialization

Signature of Applicant         

Date