Delegates Name (required) Designation / Qualication

Spouse Name

Institute

USI Membership No. :

Phone No. (Hospital)

City

E-mail

State

Cheque/DD No.

Pin code

ECS/NEFT Transaction No..

Mobile No. (Hospital)

Sender Name

Bank Name / City

Category

Address

PG. Students should attach a letter from HOD as a Proof of belonging to that College / University.Please send cheque/DD (Payable at Ahmedabad) in favour of “Minimal Access Surgery Training Institute” (Registration Fees)

You may Transfer registration form by email also on aie2018event@gmail.com and fees by ECS/NEFT also. Gujarat Medical Council accredition awaited.

Bank Details :Account Name : Minimal Access Surgery Training Institute

Account Number : 2811317766

IFSC Code : KKBK 0000812

Micr Code : 380485021

Bank Address : Kotak Mahindra Bank, Sanstar Building,

Opp. Suvidha Shopping Centre, Paldi, Ahmedabad-380007.

Dr. Kandarp ParikhOrganizing Chairman

Shyam Urosurgical Hospital4th Floor Viva Complex, Opp. Parimal GardenEllisbridge, Ahmedabad-380006, Gujarat, IndiaPh. : 079-26469846, 079-26466700E-mail : aie2019event@gmail.com

In case of any query please contact Ms Amita Bhavsar : +91 98256 57767 Ms Arpita Mehta : +91 98244 65767Please Mention Your Transaction Details in Registration Form

Registration Form

For Online Registration : www.advancements-endourology.com

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Category

USI Members

Foreign Delegates

PG Students

st to1 September 2019 th30 November 2019

st 1 December 2019

Onwards

st1 June 2019 to

st31 Aug. 2019

Early Bird Offer up tost31 May 2019

This Registration Fees includes 18% GST as per Government rules.

Note : For Foreign Delegate Registration fees should be paid only by Credit card or Debit card . NEFT Facility is not available .

12000/-

7500/-

14000/-

8000/-7000/-

10000/-8000/-

5000/-

US $ 180 US $ 200US $ 150US $ 125

13-14-15 December, 2019