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Accommodation Form
 
Title :*  
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First Name :*  
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Middle Name :  
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Last Name :*  
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Designation :  
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Gender :*  
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   Male Female
Institution / Affiliation :  
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Address :*  
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Email Id :*  
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Country :*  
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State :*  
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City :*  
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PIN :*  
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Contact Number :  
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Mobile :*  
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Fax :  
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Choice of Hotel within category :  
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Checking Date :

  
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Checkout Date :

  
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Choice of Occupancy within hotel :  
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Net Payment :  
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Payment Through Credit Card : Extra 4% Charge of will be addded in Net Payment , if payment made through Credit Card.
 
 
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Expiration Date :  
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Payment Through Online transfer Account Detail :

AMPICON2010, A/c 31115334047,

IFSC code: SBIN0007789,

State Bank of India.

Transaction ID:  
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For International Transactions: SWIFT Code: SBININBB500
Date :  
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Payment Through Demand Draft : Please make Draft in favour of “AMPICON2010”, payable at Lucknow and send to given Address:

AMPICON2010, Department of Radiotherapy Sanjay Gandhi Postgraduate

Institute of Medical Sciences, Rae Bareli Road, Lucknow 226014,

Uttar Pradesh,India