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:-