Online Registration Form
Title
*
Select Title
Prof
Dr
Mr
Ms
Mrs
Name (as you would like on your certificate)
*
Email
*
Mobile
*
Food
*
Select One
Veg
Non Veg
Designation
*
Select One
FACULTY
PAST PRESIDENT
CONSULTANT - IRIA MEMBER
CONSULTANT - NON IRIA MEMBER
PG STUDENT - IRIA MEMBER
PG STUDENT - NON IRIA MEMBER
INTERNATIONAL DELEGATE
Institute / Place of work
*
State Medical council registration number
*
State of medical registration
*
IRIA Member?
*
Select One
Yes
No
IRIA Membership Number
*
Registration Category
EARLY BIRD REG (Till August 20)
Amount
Category
INR 3000
Members PG PLM
INR 4000
Non member PG
INR 4000
Member Consultant LM
INR 6000
Non Member Consultant
Student Need to Submit Bonafide Certificate from HOD
Inclusive 18% GST
PLEASE NOTE:
Registration fees not refundable after August 30
Limited discounted accommodation (3 sharing) available at sterling resorts with all three meals (Friday dinner to Sunday Lunch) - separate google form will be sent to registered delegates only.
Accompanying Person Details
Accompanying Person Fee
INR 8500
Number of Person(s)
*
Choose
1
2
1. Name
Gender
Select
Male
Female
2. Name
Gender
Select
Male
Female
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