Name: Gender: Male /Female Email id - Conferences

Name: _______________________
Gender: Male /Female
Email id: __________________ Contact Number:
Designation:
1st year MDS / 2nd Year MDS/ 3rd year MDS / Faculty
Affiliated institution and address: __________________________________________
__________________________________________
__________________________________________
Are you a member of IAPHD:
Yes/ No If Yes, Membership No: ______________
Accompanying person if any: _______________
Have you done your BDS/MDS from MCODS Manipal/Mangalore : Yes/No
__________________
_____ ____________________
Signature
Signature and seal of the HOD *
(For PGs Only)
Online transaction details: ______________________
Registration amount and details:
Registration
August
15th 2015
October 25th
2015
Spot
registration
Faculty Delegate
10500
11500
12500
Student Delegate
9000
10000
11000
Accompanying person (non-IAPHD
member)
5000
6000
7000
Banquet only
3000
3000
3000
Non IAPHD Delegates (Other specialties)
13000
14000
15000
International delegates
$450
$500
$550
For faculty registration queries, please contact: Dr Nishu Singla (9964504403); Dr Deepak
Kumar Singhal (9379060983)
For post graduate registration queries, please contact: Dr Kush Kalra (7259590022); Dr Raashi
Raj (9901727349)
Please ensure that scanned copy of the remittance details is sent by email to
iaphdnatcon2015@gmail.com or by post to organizing committee
Payment details:
1 Beneficiary Name &
Address
2 Bank Account Number
3 Name of the Bank
4 Branch Name &
Address
5 Account Type
6 IFSC Code
7 MICR Code
8 SWIFT Code
Manipal University Conference/Workshop
Finance Department, Manipal University, Manipal
33508958510
State Bank of India
Manipal Branch, Madhuvan Serai, Ground Floor, Tiger Circle
Manipal-576104, Udupi
SB
SBIN0004426
576002006
SBININBB770
Please ensure that scanned copy of the remittance details is sent by email to
iaphdnatcon2015@gmail.com or by post to organizing committee
Postal Address :
Dept. of Public Health Dentistry,
Conference Secretariat,
20th National Conference of IAPHD,
Manipal College of Dental Sciences
Madhav Nagar, Manipal University, Manipal
Udupi district, Pincode – 576104, Karnataka.