Symposium on Medical Informatics
&
C.M.E. on Hospital Information System
September 6 - 7, 2004
Bioinformatics Centre
JB Tropical Disease Research Centre & Dept. of Biochemistry
Mahatma Gandhi Institute of Medical Sciences
Sevagram (Wardha) – 442 102, India

REGISTRATION FORM

Name: (Prof./Dr./Mr./Mrs.)________________________

_________________________________________

Age: ________________ Sex:________________

Qualification:__________________________________________

Designation: __________________________________________

Mailing Address (with PIN): ______________________________

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Telephone No. (Office) __________________________________

(Residence) ____________________Fax:___________________

E-mail: _______________________________________________

Registration Fee is enclosed: Yes / No

Accommodation required: Yes / No

Details of Payment

Registration fee : Rs _________________________

Accommodation charges: Rs __________________

Total : Rs __________________________________

Demand Draft No. ___________ Dated __________

Demand Draft in favour of "MED INFO Symposium & CME 2004", payable at Sevagram / Wardha, of any Nationalized bank may be sent to the Organising Secretary of the symposium & CME-2004.

Candidate’s Signature

Completed registration form may please be sent to the Organising Secretary

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