Registration Form
Please use capital letters. Write name as you would want to appear on the certificate
Payment by demand draft to be drawn in favour of Manipal University Conference/ workshop payable at Udupi / Manipal
Registration number is mandatory to get CME credit hours.
Name: ___________________________________________________________________________________
Gender: M/F Designation: PG/Qualified anaesthesiologist
Registration Number*:
Address: __________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Landline: ____________________ E-mail: ______________ ___________________________________________
Mobile: _________________________ Preferred mode of communication: Post Email Telephone
Optional Workshops: Statistics for beginners BLS and ACLS
____________________________________________________________________________
Details of payment:
Registration fee: Rs __________ Optional workshops: Rs _________
Total amount: Rs ___________________
DD No: _________________ Dated: ____________
Drawn on (Bank): _________________________________________ Branch: Udupi / Manipal
Date: Signature
CERTIFICATE (For postgraduate students only)
This is to certify that Dr ___________________________________ is a bonafide postgraduate student in
Anaesthesiology at _______________________________________ (college/institution)
Seal and Signature of Head of Department
Mailing address: Dr Manjunath Prabhu, Department of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka. 576 104 Email: apgap2014@gmail.com.
For online payment bank account details are as below (need to send the above application by post/email).
1.
Beneficiary Name & Address
Manipal University Conference/Workshop
Finance Department
Manipal University
Manipal-576104
2
Bank Account Number
33508958510
3.
Name of the Bank
State Bank of India
4.
Branch Name & Address
Manipal Branch
Madhuvan Serai, Ground Floor
Near Smrithi Bhavan
Tiger Circle Manipal-576104
Udupi Dist.
5.
Account Type
SB
6.
IFSC Code
SBIN0004426
7.
MICR Code
576002006
8
SWIFT Code
SBININBB770
Registration fee for Postgraduate students:
Till September 30. 2014
After September 30. 2014
CME only
Rs 3000
Rs 3500
CME and Pre-CME workshop
Rs 3250
Rs 3750
CME and BLS and ACLS workshop
Rs 12250
Rs 12750
CME, Pre CME workshop and BLS, ACLS workshop
Rs 12500
Rs 13000
Registration fee for Qualified anaesthesiologists:
Till September 30. 2014
After September 30. 2014
CME only
Rs 4000
Rs 5000
CME and Pre-CME workshop
Rs 4250
Rs 5250
CME and BLS and ACLS workshop
Rs 13250
Rs 14250
CME, Pre CME workshop and BLS, ACLS workshop
Rs 13500
Rs 14500