Registration form

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Registration form

  1. 1. REGISTRATION FORM National Conference January 28-29, 2012“Innovation in Pharmaceutical Industry:From Drug Development to Distribution” Organized by In Association with Supported byPharmanext TM L. J. INSTITUTE OF PHARMACY AHMEDABAD Gujarat Technological University (GTU) B.V. Patel PERD Center Pin Code Pin Code Phone Numbers with STD code Cell S. No. Please tick Please send the form along with the relevant details to:Pre C o nfe re nce Wo rk s h op L. J. Institute of PharmacyAccom o da t i o n i nt e re st ed Nr. Nagdev Mandir, Sanand-Sarkhej Circle, S G Road, Ahmedabad - 382210 (Gujarat) Contact : 8141800084/9427801975/9818455437 REGISTRATION Email : pharmanextahmedabad@gmail.com, Early bird Registration* Before Nov 30, 2011 Before Dec 30, 2011 www. pharmanextahmedabad.com, www.pharmanextworld.com Student INR 1000 INR 2000 INR 3000 ENQUIRIES & DETAILS Professional INR 2000 INR 3000 INR 5000 Mr. aayush Agarwal : 8141800084 From Industry INR 3000 INR 5000 INR 7000 Mr. Chintan Oza : 9427801975 Workshop INR 1000 INR 1500 INR 3000 Mr. Harish Pal : 9818455437 * Early bird registration is applicable before October 30, 2011. Email: pharmanextahmedabad@gmail.com pharmanext@hotmail.com Enclosed Rupees ___________________________________________ Bank Transfer __________________________________________________ (in words) Bank Name : ICICI BANK LIMITED Rs.__________________________(in figures) through Demand Draft / Branch : B 78, Defence Colony, New Delhi -110024, India Account Name : PHARMANEXT Cheque drawn in favour of “Pharmanext” payable at Delhi. Account Number : 630005008543 Name of the Bank___________________________________________ Swift Code : ICICINBBCTS IFSC Code : ICIC0006300 D.D./Cheque No. ___________________Dated __________ Place ___________ Date :_______ Signature ____________ Registration is non refundable and non transferable. ( No refund in case of cancellation. Only registered delegates will be allowed to attend the conference)

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