Organised by Division of Gastroenterology KEM Hospital Pune
Registration Form
Name:
Institution:
Mailing Address:
City:
M/F
Pincode:
Telephone: (Resi)
MMC Reg. No.
Department:
Email:
(Off)/Clinic
Mobile:
Delegate
PG student #
A. Endoscopy Workshop on 14/4/2012
(Limited to first 125 delegates only)
B. CME programme on 15/4/2012
Rs. 750/-
Rs. 400/-
Rs. 500/-
Rs. 300/-
A + B. Endoscopy Workshop + CME
Rs. 1000/-
Rs. 650/-
Participation: (Please tick category)
(See instructions below)
Total Amount:
Payment Details: (All payments by Local cheques/Demand Draft drawn in favour of ‘KEM Hospital ‘payable at
Pune only. )
Demand Draft No.:
Amount:
Drawn on Bank:
Dated:
Signature
# Letter from HOD to be enclosed by PG students
Important Instructions
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To verify availability for Endoscopy Workshop contact Mrs. Namrata Tel: 020 66037364 between 9.30am
to 4.30 pm on working days
Registration if includes Endoscopy workshop to be sent only to Conference secretariat
Registration for CME without workshop also arranged at IMA Pune
Attach photocopy of MMC certificate/MMC Photo ID
Conference secretariat: Division of Gastroenterology, TDH Bldg, KEM Hospital Pune 411011 Tel: 020 66037364
Visit us at www.kemhospital.org; Email: giendoscopy@kemhospital.org