Faculty of Pharmacy Parul Institute of Pharmacy in association with

Gujarat State Pharmacy Council Organizes

Two Days Refresher Course for Registered Pharmacists (21st and 22nd January, 2017) REGISTRATION FORM Name: __________________________________________________________________ (Surname)

(Middle Name)

(Last Name)

Date of Birth: ____ /_____/_______

Age: ___________

Qualification: __________________

Designation: ______________________

SPC Reg. No.: _________________

Date of last Renewal: ____ /_____/_______

Contact No.: __________________

E mail ID: ____________________________

Name and Address of present Institute / Organization: _________________________________________________________________________ _________________________________________________________________________ Address of communication: ________________________________________________________________________ _________________________________________________________________________ Registration fees: 300/- INR For online payment Name of Bank: Central Bank of India

Branch: Parul Institute of Engg Tech, Limda

Account no: 3499168849 (Saving Account)

IFSC Code: CBIN0284063

For payment by Demand Draft It should be payable to “Parul Institute of Pharmacy Events” Name of Bank: ________________________ DD No: _________ Date: ____ /_____/_______

Date: ___ /____/____

Signature of the Applicant

Note:  Please attach a self attested photo copy of Registration Certificate of State Pharmacy Council and Renewal Receipt with Registration form.  Incomplete form or form without documents will not be accepted. Communication Address: Faculty of Pharmacy, Parul Institute of Pharmacy, Parul University, P.O. Limda, Ta. Waghodia, Vadodara –391 760 Phone: 02668-260232/224 E-mail: [email protected]; Web site: www.parul university.ac.in