Registration form - asian pacific association for study of the liver

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REGISTRATION & ACCOMMODATION FORM
ASIA PACIFIC ASSOCIATION FOR STUDY OF LIVER
SINGLE THEME CONFERENCE
HCV Infection & Disease, Is cure for all Infected in sight!
Hotel Ashok, New Delhi, India
21 – 23 August, 2015
REGISTRATION FORM
Please fill in BLOCK LETTERS/tick where appropriate
Title
: Prof.
Name
: _________________________________________________________________
(Similar to how it needs to appear on the certificate/ ID card)
Designation
Dr.
Mr.
Ms.
Gender:
M
F
Age: _______
: __________________________________________________Institution: ____________________________________________________
Address for Communication: ______________________________________________________________________________________________________
______________________________________________________________________________________________________
Town / City: ________________________ Pin Code: ________________ State: _______________________________ Country: ______________________
Telephone (Nos): STD Code :_______ (Office) _______________________ (Res.)_____________________ Mob: _________________________
Email: ____________________________________________________________________________________________________
Name (s) of the Accompanying Person (s)
(1) _______________________________________________________________________________(2) ________________________________________________________
Please find enclosed herewith Cheque/DD of Rs. _____________________________________ Cheque/DD No _______________
dated __________________________drawn on (name of bank) ____________________________________________________
in favour of "---------------------------------------" payable at New Delhi, India.
Details for Payment (wire transfer) of registration fee are as following:
Name of the Bank:
Address of the Bank:
A/c & Beneficiary Name:
Bank A/C Number:
Branch Code:
IFSC Code:
Swift Code:
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Kindly Note:

Bank charges pertaining to the sender’s bank and/or the intermediary bank will be payable by the sender. The amount
remitted to the bank account of the conference secretariat should be equivalent to the registration amount due.

For the delegates from India, sending their registration money by wire transfer, they should send the UNIQUE
TRANSACTION REFERENCE NUMBER (UTR) along with the wire transfer certificate.
Date:
Signature of Delegate
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