REGISTRATION FORM

SAFCON-2007

SOUTH ASIAN AND VII ANNUAL NATIONAL CONFERENCE OF

March 24-25, 2007

www.icfmt.org

DEPARTMENT OF FORENSIC MEDICINE AND TOXICOLOGY, JAWAHARLAL NEHRU MEDICAL COLLEGE, ALIGARH MUSLIM UNIVERSITY, ALIGARH

REGISTRATION FORM* [SAFCON-2007]

Full Name: Mr/Ms/Mrs______________________________________________________

Designation/ Title_________________________________________________________

Department:_____________________________________________________________

Name of the Institution:_____________________________________________________

Full Correspondence Address:______________________________________________

______________________________________________________________________

Country/ State with Pin Code /Zip Code:_______________________________________

Telephone Number:_____________________________ [Preferred Phone number for contact]

Mobile Number___________________________________________________________

Co-delegate’s Name/Gender:______________________________________________

Number of Accompanying Children [If any]______________________________________

Your E-mail ID:__________________________________________________ [Mandatory]

Title of the Abstract[s] sent: ______________________________________________________

____________________________________________________________________________

Registration Fee for Delegates

Delegate Fee	Rs 2,000/- [$ 50]	Only up to 31^st December, 2006
	Rs. 2,500/ [$ 70]	On the spot
Co-Delegate/Spouse	Rs. 1000/- [$ 25]	--
PG Students/Residents/SRs	Rs. 1000/- [$ 25]	Only up to 31^st December, 2006
	Rs 1500/- [$ 30]	On the spot
Interns/UG Students[From outside India only]	Rs 500/- [$ 15]	Only up to 31^st December, 2006
	Rs 600/- [$ 20]	On the spot

Payment Details:

PLEASE MARK THE BANK DEMAND DRAFTS/CHEQUE PAYABLE AT ALIGARH & IN FAVOUR OF THE

“SAFCON-2007”

[Account Number: 30063817878][Branch Code: 3570]

[ State Bank of India, Medical College Branch, Aligarh ]

DD/Cheque Number/Name of the Issuing Bank: ______________________________________

Dated:___________________________ Amount:____________________________________

Remarks [if any]:_______________________________________________________________

Date:

SIGNATURE OF DELEGATE

*PG/UG Students/Interns are required to enclose a certificate of affiliation issued by the Head of their respective institutions.

SAFCON-2007
Department of Forensic Medicine & Toxicology
Jawaharlal Nehru Medical College,

Aligarh Muslim University,

ALIGARH-202002.

INDIA

Phone: +91571272038; +915712720926
Telefax: +915712720926

E-mails:

safcon2007@yahoo.com

Helpline E-mail:

webmaster@forensicindia.com
[For Any Query Concerning SAFCON-2007]

For more information, please visit our
Websites: www.forensicindia.com