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Conference Registration

First Name*

Sur Name*

Address*

City*

State*

Pin

Country*

email*

Phone

Area of Works

Pre-hospital, Emergency Department,
Trauma, Disaster Management, Academia,

Emergency Medical Services, Critical Care, Others

(Others)

Organization/Institution:*

Designation:

SEMI Membership No:

Accompanying Spouse:

Yes
No

Name of Spouse:

Food Preference:

(for conference lunch/dinner)

Veg
Non Veg

Category : (Please tick one)

Category		Inclusions	Date		Registration Fees
Category		Inclusions	From	Till	Registration Fees
Delegates
	Early Bird		30th June	30th Sept	Rs. 3,000
	Regular		30th Sept	31st Oct	Rs. 4,000
	Late & Spot		1st Nov		Rs. 5,000
	Student			31st Oct	Rs. 2,000
	Foreign			31st Oct	Rs. 4,000
	Spouse of delegates			31st Oct	Rs. 1,500
	SAARC			31st Oct	Rs. 4,000
Faculty
	Faculties – National	AC Accommodation		31st Oct	Rs. 4,000
	Faculties – International and SAARC	AC Accommodation		31st Oct	Rs. 4,000
	Spouse of Faculty			31st Oct	Rs. 2,000
Late & Spot registration from 1st November onwards Rs. 5,000/-

Payment Details :

Enclosed please find DD/Cheque No.: Dated

for rupees drawn on in favor of INTEM2010 payable at Vadodara towards registration fees.

* Marked fields are mandatory

Note:

Payment to be sent to : INTEM2010 secretariat, E-501, Kalpavruksh, Gotri Road, Vadodara – 390 021.
If your spouse is accompanying you, please fill a separate form and pay registration fees accordingly.
If you are a faculty, please send your travel plans latest by 31st October 2010.
Registration fees for more than one delegate or spouse can be paid through one dd/cheque. But, include all registration forms along with payment.
Registration includes entry to all conference halls, breakfast, lunch, tea/coffee.
Student registration will only be allowed if accompanied by a bonafide certificate issued by the University (and not the department).
All registered delegates, faculties and spouses (of registered delegates/faculties) who have registered separately are invited to...