Welcome to the MAPICON - 2003 at Cidade de Goa ..... Organised by KONKAN Chapter of API

THE REGISTRATION FORM

Name:
Age:
Address:
Address 1:
Pin:
STD Code:
Tel - Clinic:
Tel - Res:
Mobile:
E-Mail:
Web Site:
Hospital Attachments:
Regn. No. - MMC:
API Membership No.:
Practising Internal Medicine since:

I would like to present a Cultural Program on 18.10.03 - SONG
Hindi:   Marathi:   Mimicry:   Others:

PAYMENT DETAILS

  1. Registration Charges
  2. Workshop Fees
  3. Accompanying persons
    • A.
    • B.
    • C.
  4. Accommodation Charges @ venue are Rs. 10,500/- per room for 3 days for 2 persons.
Bank DD No.:
Amount:
Date:
Drawn on:
Branch:

Bank Draft should be drawn on:
MAPICON - 2003
payable at either Khopoli, Dist. Raigad or Sindhudurg, Sawantwadi Dist.
You can post it to:
DR. S V KULKARNI
144, L.B.S. Nagar, Khopoli - 410203, Dist. Raigad
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