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Registration & Accommodation Form
 
Title :*  
:
  
First Name :*  
:
  
Middle Name :  
:
  
Last Name :*  
:
  
Designation :  
:
  
Gender :*  
:
   Male Female
Institution / Affiliation :  
:
  
Address :*  
:
  
Email Id :*  
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Country :*  
:
  
State :*  
:
  
City :*  
:
  
PIN :*  
:
  
Contact Number :  
:
   - -
Mobile :*  
:
   -
Fax :  
:
   - -
Type of Registration:  
:
  
Ampi Membership No.:  
:
  
No. of Associate Delegates :  
:
  
Associate Delegate Name(s):  
:
 1.
   
:
 2.
Accommodation Required :  
:
   Yes No
Select the category :  
:
  
Choice of Hotel within category :  
:
 1.
   
:
 2.

Checking Date :

  
:
   DD/ MM/ YY

Checkout Date :

  
:
   DD/ MM/ YY
Choice of Occupancy within hotel :  
:
  
Net Payment :  
:
  
Mode :*  
:
  
   
 
Payment Through Credit Card : Extra 4% Charge of will be addded in Net Payment , if payment made through Credit Card.
 
 
Card Type:  
:
  
Card Number:  
:
  
Expiration Date :  
:
   MM/ YY
Card Verification Number :  
:
  
 

Payment Through Online transfer Account Detail :

AMPICON2010, A/c 31115334047,

IFSC code: SBIN0007789,

State Bank of India.

Transaction ID:  
:
  
For International Transactions: SWIFT Code: SBININBB500
Date :  
:
   DD/ MM/ YY
 
 

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