UTTARA EYECON 09- REGISTRATION FORM

6th Annual Conference of
Uttarakhand State Ophthalmological Society
October 2nd, 3rd & 4th 200

REGISTRATION FORM

NAME………………………………………………………………………………………………………………………………………………………………………………

ADDRESS………………………………………………………………………………………………………………………………………………………………………….

……………………………………………………………….. STATE…………………………………………….PIN………………………………………………………

TEL. (O)……………………………………. (R)……………………………MOBILE………………………………….E-Mail…………………….…………………

Accompanying Persons:
SPOUSE NAME………………………………………………………………………………………………………….……………
CHILDREN (ABOVE 12YRS) 1. ………………………...……………….… 2. ……………………………..……………….
CHILDREN (7 TO 12YRS) 1. ……….…………………...……………… 2. ……………………………..……………….

Complimentary Pre- conference Registration on 2nd Oct. Yes / N0
Hotel Accommodation required- Yes / No
For Hotel Accomodation Contact DR. SATANSHU MATHUR PH 9837120191
( One night advance deposit required)

Category Before 15th
Sept. 09 After 15th
Sept. & Spot
Delegate
(Member UKSOS) 1500/- 1800/-
Delegate
(NON-Member) 1800/- 2200/-
Resident 800/- 1000/-

Enclosed: a) Delegate registration fee Rs ________ b) Total Rs __
ENCLOSING THE TOTAL AMOUNT (IN WORDS)…………………………………………………………………………..……………………………………..
……………………………………………… BY CASH /DEMAND DRAFT NO …………………………………………... DATE………………………………….
DRAWN ON BANK ………………………………………………………….IN FAVOUR OF “UTTARAEYECON 2009”PAYABLE AT RUDRAPUR

TRAINS FROM IMPORTANT STATIONS TO KATHGODAM(26KM. FROM BHIMTAL)
From Train Name Train No Departure Time (Hrs) Arrival Time (hrs)
DELHI UTR.SAMPRK K EXP. 5035 16:00 22:40
DELHI RANIKHET EXP. 5013 22:45 6:05
LUCKNOW BAGH EXP. 3019 00:30 9:30
LUCKNOW NAINITAL EXP. 5308 20:55 6:10
DEHRADUN DDN KGM EXP. 4320 22:30 7:17
Mailing Address
DR ANURAG GARG (Organizing Secretary)
PRAKASH EYE HOSPITAL & LASER CENTER ,DOCTOR COLONY, CIVIL LINES, RUDRAPUR
PH: 05944-246946 FAX- 242394, MOB: 9837180286 E-Mail:uttaraeyecon2009@gmail .com

FOR OFFICE USE ONLY Receipt No. Regn. No.