17TH ASIAN OCEANIAN CONGRESS OF RADIOLOGY AND 71ST NATIONAL CONFERENCE OF THE INDIAN RADIOLOGICAL AND IMAGING ASSOCIATION.
REGISTRATION FORM [ ]
[ ] PG Student
IRIA Member
[ ] Accompanying Delegate
IRIA Membership Number *not applicable for PG students and accompanying delegates
First Name Last Name Mobile No.
Email Address
Medical Council Age
Medical Council Reg. No. Designation
Company / Institute Mailing Address Line 1 Mailing Address Line 2 Mailing Address Line 3 City
State
Country
Pin-Code
Accompanying Delegate First Name Accompanying Delegate Last Name Accompanying Delegate Email Address *All PG students must attach a letter by the HOD
SCHEDULE OF FEES UPTO JAN 31st
UPTO OCT 31st
UPTO DEC 31st
IRIA Member
7,000/-
8,500/-
11,000/-
Accompanying Delegate
7,000/-
7,500/-
11,000/-
Student
7,000/-
7,500/-
11,000/-
Trade
7,000/-
8,500/-
13,500/-
ACCOMODATION - UPTO JAN 31ST (Please circle the accomodation package) ACCOMODATION TYPE
SINGLE ROOM
TWIN SHARING
FAMILY ROOM
3N.4D
4N.5D
3N.4D
4N.5D
3N.4D
4N.5D
Luxury Accommodation
23,000/-
33,000/-
13,000/-
18,000/-
26,000/-
36,000/-
Standard Accommodation
11,000/-
15,000/-
7,000/-
10,000/-
14,000/-
20,000/-
17TH ASIAN OCEANIAN CONGRESS OF RADIOLOGY AND 71ST NATIONAL CONFERENCE OF THE INDIAN RADIOLOGICAL AND IMAGING ASSOCIATION.
ACCOMODATION - UPTO OCT 31ST (Please circle the accomodation package) SINGLE ROOM
ACCOMODATION TYPE
TWIN SHARING
FAMILY ROOM
3N.4D
4N.5D
3N.4D
4N.5D
3N.4D
4N.5D
Luxury Accommodation
24,500/-
35,000/-
14,500/-
19,500/-
29,000/-
39,000/-
Standard Accommodation
12,500/-
16,500/-
8,500/-
11,500/-
17,000/-
23,000/-
ACCOMODATION - UPTO DEC 15TH (Please circle the accomodation package) SINGLE ROOM
ACCOMODATION TYPE
TWIN SHARING
FAMILY ROOM
3N.4D
4N.5D
3N.4D
4N.5D
3N.4D
4N.5D
Luxury Accommodation
26,000/-
37,000/-
16,000/-
21,000/-
32,000/-
42,000/-
Standard Accommodation
14,000/-
18,000/-
10,000/-
13,000/-
20,000/-
26,000/-
Payment to be made in Check/ Cash/ DD/ NEFT payable at par in __________ Name of Account
:
Name of Bank
:
Name of Branch
:
Account Number
:
Type of Account
:
IFSC Code
:
Swift Code
:
Signature
AOCR2018 MSBIRIA Office - 808, Crescent Business Square, Kherani Road, Opposite Gundecha Onclave, Near Saki Naka Metro Station, Saki Naka, Andheri (E), Mumbai 400072 Tel: 022-65088822 • Email:
[email protected] • Website: www.aocr2018.org