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 5)
Amount
Category
INR 3000
Members (LM / PLM)
INR 4000
Non Members
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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