1. REGISTRATION FORM
National Conference
January 28-29, 2012
“Innovation in Pharmaceutical Industry:
From Drug Development to Distribution”
Organized by In Association with Supported by
Pharmanext
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 Pharmacy
Accom 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)