Registration Form

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International Conference
on
Control, Instrumentation Energy & Communication (CIEC16)
Organized by Department of Applied Physics, University of Calcutta
January 28- 30, 2016
REGISTRATION FORM
NAME:-________________________________________________________________________________________________
DESIGNATION:-________________________________________________________________________________________
AFFILIATION:-_________________________________________________________________________________________
ADDRESS:-_____________________________________________________________________________________________
CITY:-_____________________STATE:______________________________PIN/ZIP: ________________________________
COUNTRY:____________________________________________NATIONALITY:___________________________________
CONTACT NO.:-______________________________E-MAIL ID:-________________________________________________
CATEGORY:
A) Author
B) Author (IET/IEEE member)
c) Non author
d) Spouse/ family member
WHETHER IET/IEEE MEMBER? NO/YES
Membership No.______________________________ Membership Society/Organization _______________________________
FOR AUTHOR REGISTRATION FURNISH THE FOLLOWING DETAILSPAPER ID: - ________________________________________NUMBER OF PAGES:-________________________________
TITLE:-________________________________________________________________________________________________
_______________________________________________________________________________________________________
PAYMENT DETAILS:MODE OF PAYMENT: -
Demand draft
Cheque
Online Transfer
AMOUNT (INR) :____________________
AMOUNT (in words):- ___________________________________________________________________________________
CHEQUE/DD/TRANSACTION ID NO.:- _________________________________DATE OF ISSUE:-____________________
SENDER’S NAME (for online transfer):- _____________________________________________________________________
BANK DETAILS:-_______________________________________________________________________________________
_______________________________________________________________________________________________________
DECLARATION
I hereby declare that all statements made above are true to the best of my knowledge. I understand and agree to abide by all the
terms and conditions of the conference.
__________________________________
FULL SIGNATURE
DATE:-
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