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Registration Form

SECTION 1: REGISTRATION DETAILS

    Name: Prof./Dr./Mr./Ms

    Designation:

    Course Details (If, student)

    Organization/Affiliation:

    Age:

    Sex:

    Area:

    Specialization (Subject):

    Postal Address:

    Mobile No.

    Landline No.:

    Primary email (Compulsory):

    Alternate email (if available):

    Are you submitting abstract in this symposium?

    YesNO

    Assistance for booking accommodation required?

    YesNO

    SECTION 2: PAYMENT DETAILS

    Please tick one Type of Registration

    Early/Standard Registration: (On or before 15th November, 2013, 01st December, 2013)

    Early Delegate Registration Rs. 4000/-Standard Student Registration Rs. 3000/- Late Registration: (After <del>15th November, 2013,</del> 01st December, 2013)Late Delegate Registration Rs. 5000/-Late Student Registration Rs. 4000/-Cash (if registration form handed over in person)Cheque / Demand Draft (DD)

    Cheque* /DD No.

    Date:

    Bank

    Branch:

    * For outstation cheques, please add additional ` 100 towards clearance charges

    INSTRUCTIONS

    Student Registration: Please use one form per person. Make a copy of this completed form for your record and return this original completed form, via post / courier to the Symposium Secretariat. Registration forms sent without payment and registration details will not be processed.

    Registration Form: Students need to submit Xerox copy of student identity card OR a bonafide letter from the Head of the Department of their respective college / institution. This has to be sent along with the registration form and DD.

    Payment Information: Registration forms must be accompanied by full payment in order to be processed. Incorrect DD numbers and invalid details are considered non-payments and registration will not take place. No registrations will be accepted by telephone.

    Refund policy: No refund will be given but the registration can be transferred to substitute delegates without penalty.

    Deadlines: Registration to the symposium is done on a first-come, first-served basis. Therefore, participants are requested to register at the earliest to secure registration.

    Confirmation:Please allow up to 3 days for eMail confirmation of your registration, after receipt of Cheque /DD and registration form at the symposium secretariat.

    Contact Us:Should you have clarification regarding registration, please contact the Symposium Secretariat at HIVSymposium@yrgcare.org.

    DECLARATION

    The information provided in the registration form is true and correct to the best of my knowledge. I have taken notice of the registration instructions on this form.

    Date:
    Place:
    Signature:

    The Symposium Secretariat

    2nd International Science Symposium on HIV & Infectious Diseases

    YRG Centre for AIDS Research and Education

    Voluntary Health Services Hospital Campus

    Taramani, Chennai – 600113

    eMail: HIVSymposium@yrgcare.org

    Web: http://HIVSCIENCE.yrgcare.org

    Tel:044-39106800/01/02/03/04/05