GENDER MALE FEMALE

ADDRESS ___________________________________________________________________________ _____________________________________________________________________________ CITY : ______________ STATE : ________________ PIN CODE : __________________________

CONTACT NUMBERS LANDLINE : ______________________ MOBILE : _____________________________________

EMAIL ID ______________________________________________________________________________

IF MEMBER MDRT COT TOT MDRT ID : _________________

MEAL PREFERENCE VEGETARIAN NON VEGETARIAN JAIN

PAYMENT MODE CHEQUE DEMAND DRAFT

PAYMENT DETAILS CHEQUE / DEMAND DRAFT NUMBER : _________________ AMOUNT : _____________________ DRAWN ON BANK : __________________________________ DATED : _________________________

:

:FIRST NAME ____________________________ SURNAME : __________________________

INSURANCE COMPANY __________________________________________________________________

REGISTERED MDRT MEMBER FOR 2014 or 2015 NON MEMBER CATEGORY

Duly filled form along with Transac�on slip / ID (if paid by NEFT) or Cheque / Demand Dra� favouring ‐“RIPPLEZ XPERIENTIAL MARKETING A/C MDRT DAY 2015” payable in Mumbai, to be mailed to :Ripplez Xperien�al Marke�ng, 1st Floor, Office 33, Om Heera Panna Mall, Oshiwara, Andheri (West), Mumbai 400 053

DETAILS FOR NEFT BANK NAME ‐ IDBI BANK, BRANCH ‐ BHAYANDAR (WEST) ACCOUNT NUMBER ‐ ________________________IFS CODE ‐ _________________________

NEFT

DELEGATE REGISTRATION FORM

1. Early bird registra�on fee 5,500/‐ (inclusive of Service Tax) up to December 15, 2014.2. Regular registra�on fee 7,000/‐ (inclusive of Service Tax) December 16, 2014 to January 31, 2015. 3. Receipts with your Registra�on Number will be mailed to the address provided. Kindly carry the same on the day of the event. Entry will be granted only on produc�on of the Receipt.4. Registra�ons once done cannot be cancelled. No refunds will be provided. Subs�tu�ons will be accepted on or before January 20, 2015.5. The organizer reserves the right to make any amendments and/or changes to the program, venue, speaker replacements and/or topics if warranted by circumstances beyond control.6. Delegate fees include Conference sessions, breakfast, tea/coffee breaks and lunch.7. 2014 & 2015 Registered MDRT/COT/TOT Members will be en�tled to Special Reserved Sea�ng.8. Delegate fees do not include travel and lodging.9. Confirma�on of registra�on is subject to clearance of Cheques. Out sta�on cheques should be payable at PAR in Mumbai.

SIGNATURE : ____________________________

TERMS & CONDITIONS:

DATE : _____________ PLACE : _____________

0536102000014119 IBKL0000536