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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)

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Registration form

  • 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)