Conference Registration Form We are nominating the following official(s) from our organization to attend the above conference. Sr. No.

Name of the Participant

Designation

Mobile No.

Email

1 2 3 4 5

DD/Cash/ECS/Cheque No. ___________dated ________________ for Rs. __________ towards participation fee drawn in favour of S. R. Luthra Institute of management payable at Surat is enclosed.

Nominated / Registered by: Name : Designation : Organization : Address : City : Tel : Mobile No :

__________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ _______________________Pin Code:_____________________ ________________________________ Fax :_____________________ _____________________ E-mail: _______________________________

Particulars

Students/Research Scholars Academicians Industry/Entrepreneurs Paper Submitted in Absentia

Early Bird Offer Amount (Rs) on or before 15th January 2015

Regular Amount (Rs)

500/-

600/-

1000/-

1200/-

1000/-

1200/-

1200/-

1500/-

(Signature) Contact Details: Dr. Hemlata Agarwal: 9879509635, Ms. Rupal Khambhati : 9879403052 , Ms. Esha Pandya : 9998291259 ------------------------------------------------------------------------------------------------------------------------------------------------------------S. R. Luthra Institute of Management, M.T.B. College Compound, Near Adarsh Society, Athwalines, Surat. Tele : 0261- 2240 103/2240 129, Website:www.srlimba.org, E-mail:[email protected]

Conference Registration Form Nominated ... -

We are nominating the following official(s) from our organization to attend the above conference. Sr. No. Name of the Participant. Designation. Mobile No. Email.
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