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The document appears to be a registration form for a 2020 Virtual Cytopathology CME conference, requesting information such as name, designation, institution address, and payment details including amount paid, mode of payment, and bank account information for depositing registration fees via NEFT transfer. The form also specifies that the CME portion of the event is free while there is a 250 rupee charge for e-Poster participation.

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Naman Agarwal
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109 views1 page

Form

The document appears to be a registration form for a 2020 Virtual Cytopathology CME conference, requesting information such as name, designation, institution address, and payment details including amount paid, mode of payment, and bank account information for depositing registration fees via NEFT transfer. The form also specifies that the CME portion of the event is free while there is a 250 rupee charge for e-Poster participation.

Uploaded by

Naman Agarwal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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2020

REGISTRATION FORM

Title - Prof.
Dr. Mr. Ms. Mrs.

First Name .............................................................. Middle Name .............................................................. Last Name .............................................................

Designation ..................................................................................................................................................................................................................................

Institutional Address .....................................................................................................................................................................................................................

City ............................................................................... State ............................................................................... Pin ..............................................................

e-mail .......................................................................................................................................... Contact ..................................................................................

AMOUNT PAID FOR

CME........................................FREE
e-Poster..................................250 `

MODE OF PAYMENT
NEFT Net Banking

PAYMENT DETAILS

NEFT Transaction No. ............................................... A/c No. .......................................................... Date .............................

Date ....................................... Signature .......................................

CONFERENCE ACCOUNT DETAILS


 NEFT in favor of “Virtual Cytopathology CME 2020” payable at Bareilly, U.P.
 A/C. No. : 52241010000010
 A/C. Type : Saving Bank
 IFSC : ORBC0105224
 BANK : Oriental Bank of Commerce
SRMS-IMS Branch, Bhojipura, Bareilly-243202
 Contact No. : 9458705005
 E-mail ID : secretaryiacup@gmail.com
cytopathologycme2020@gmail.com

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