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 upto Nov’30,2007
Registration after Nov 30,2007
 Amount
Payable
International Delegate
US $ 300
US$ 400
  
IAOH / ICMA Members
Rs. 3,500
Rs. 5000
  
Non Member
Rs. 4,500
Rs. 6000
  
PG Student
Rs. 850
Rs. 1000
  
Retired Member
Rs. 750
Rs. 1000
  
  Accompanying Person
Rs. 1000/- or US $ 100
Rs. 1500/- or
US $ 150
  
Workshop [Limited Seats]
Rs. 1500 Each
  
  Total  

By Cheque / DD (Please take a print out of this form & send it to the organizing secetary) By Credit Card

Conference Registration Fee Covers:
Admission to attend the Conference, Delegate Kit, Inaugural Ceremonies, Lunches &
Tea/Coffee on all days at the venue, Social programmes and Cocktails & Banquet.
PLEASE indicate your intention below:
[ ] to attend the conference [ ] like to receive information [ ] wish to present a
Scientific Paper/Poster
All Payments payable at Mumbai, in favour of
INDIAN ASSOCIATION OF OCCUPATIONAL HEALTH-Mumbai Branch, .


Payment by: [ ] Demand draft [ ] Credit Card:
Please debit my [ ] VISA [ ] MasterCard VALID THRU: /

Card Holder’s Name (As on the card):__________________________

Card No: [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ]

Total Payment: Rs./USD.______________________________________

Date signed: ____/____/______ Signature________________________

 
 
Mumbai Branch Committee
President
Dr H.M.Haldavnekar

Vice Presidents
Dr C.S.Gulvady
Dr K.P.Madhwani

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