::IAOH::

REGISTRATION FORM

DIAMOND JUBILEE CONFERENCE

60th NATIONAL CONFERENCE OF INDIAN ASSOCIATION OF OCCUPATIONAL HEALTH HYDERABAD

REGISTRATION FORM

Field marked with asterisk (*) are mandatory

Title *
( ) Dr ( ) Mr ( ) Ms ( )Prof

Family Name *

First Name

Address

City / State

Zip / Postal Code

Country *

Phone *
(Eg: 91-11-2200000)

Country Code	Area Code	Phone Number

Fax
(Eg: 91-11-2200000)

Country Code	Area Code	Fax Number

Email*

Accompanying Person

Registration Fee

Categories

Registration

Amount
Payable

International Delegate

Rs. 16,000

IAOH Member

Rs. 5000

Non Member

Rs. 6000

Retired Member

Rs.1000

Accompanying Person

Rs.1500/- or
Rs. 6000

Workshop [Limited Seats]

Rs. 1500 Each

Total

If paid by Cheque / DD Please take a print out of this form &send it to the organizing secetary

Registration Fee Details

Demand draft No.

Date

Amount

For accommodation contact directly as per the details given in the last page of the brochure.