1. Indian Statistical Institute, SQC & OR Unit, Bangalore
PROGRAM
for
DESIGN FOR SIX SIGMA (DFSS) BLACK BELT (DFSS - 1)
17 – 21 January 2011 & 04 – 08 April 2011
Registration Form
Organization :
Contact Person :
Mailing Address :
E-mail : Phone:
Fax : Mobile:
Details of the participants attending the program:
Name Position e-mail Mobile Accomo-
dation
Desired?
1.
2.
3.
4.
5.
Note: Please provide Proof of Eligibility (Refer Brochure) of the nominated participants
Please provide a) Calculations (next page) for total amount payable, and b) Details (below)
DD attached Amount: Cash Receipt copy attached
(in favour of “Indian Statistical Institute” payable at Bangalore)
Amount:
DD No.: Date:
Recpt. # :
Bank: Branch: Date :
Signature : Name :
Date :
P.T.O.

2. -- 2 --
Calculation of Amount Payable:
Participant Accommodation Amount
Needed? (Y/N)
1
2
3
4
5
A. Sub Total
B. Less: Discount for Member Organization/
Self-sponsoring participants, if applicable
C. Less: Discount for Group Participation if applicable
D. Total Amount Due (A – B – C) :
E. ADD: Service tax @ 10.30% (10.30% of (D) ):
F. Total Amount Payable (D + E) :
_________________________ ______________________________________
***** Photo copy of this form may be used in case of more participants *****
Please e-mail the form to: kalyancho@gmail.com,
kspk1990@gmail.com
Or, Send to: K.K.CHOWDHURY
Program Director: DFSS - 01
SQC & OR Unit
Indian Statistical Institute
8th Mile, Mysore Road
Bangalore – 560 059,
INDIA Fax: +91 80 2848 4910
__________________________ ______________________________________
For Office Use