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REF Events : Multi-Disciplinary Session on Interstitial Lung Diseases VII at Indian Habitat Centre, Delhi - 2nd March 2019

Registration Form :
Online Registration for those who are paying by Credit Card.

First Name:
Last Name:
Event:
Radiologist/Chest Physician:
Address:
City:
State :
Pin Code:
Contact No. (Mandatory):
E-mail (IMP):
Institution:
Please Choose: Consultant
Resident
Medical Council Registration Number (IMP):
Name of Head of Dept:

Amount Rs:

Please enter a numeric value in the box e.g. 3000. Please DO NOT enter any text or non-numeric characters in the box. (credit card payment)
  
 

Please Note:

If payment is not being made by credit card, then please send a demand draft in favor of "Radiology Education Foundation, A/C Conference" for Rs. 3000/-.

PLEASE DO NOT FILL UP THIS ONLINE FORM IF PAYMENT IS BY DEMAND DRAFT OR CASH.

PLEASE PRINT A COPY OF THIS FORM AND SEND IT BY COURIER WITH THE PAYMENT ALONG WITH THE SIGNATURE OF THE HEAD OF DEPARTMENT, FOR PURPOSES OF VERIFICATION. THIS HAS TO BE DONE EVEN IF THE PAYMENT IS BY CREDIT CARD.

*Credit Card payment: REF is pleased to announce that we now accept national and international credit cards! The transaction is secure and done through Axis Bank.. As soon as we get intimation about your payment, you will be issued the registration number by email, and this will serve as your receipt.


To pay by Cash or Demand Draft please print the form, fill it up with the relevant details and mail it to the address given below. Please write your name on the reverse of the DD. Please fill in the following:
DD No:
Date:
Bank:
Amount :

Please send the printed form along with cash/DD to the following address:
Radiology Education Foundation,
"F", 1st Flr, Bhaveshwar Vihar,
383 Sardar V P Rd,
Mumbai 400 004.
Tel 022-66173333

Attn: Ms. Shamina

Fax 022-2382-9595

 

 

 

 

 

 

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