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:
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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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