PFAM XVII

Registration Form

* Mandatory Fields

Select a category

Title*

First Name*

Last Name

(3 - 25 characters)

Abstract Id / Ref No.*

Affiliation*

Address*

City*

Country*

Phone*

("0-9", "-", "+", " ")

Email*

(6 - 25 Characters)

Payment Details :-

Category/Registration

Amount

		INR 12,000
		INR 6,000
		INR 3,000
	(Non-participants:Spouse/Parents etc.)

		USD 600
		USD 300
		USD 200
	(Non-participants:Spouse/Parents etc.)

Title*

First Name*

Last Name

(3 - 25 characters)

Affiliation*

Address*

City*

Country*

Phone*

("0-9", "-", "+", " ")

Email*

(6 - 25 Characters)

Payment Details :-

Category/Registration

Amount

		INR 12,000
		INR 6,000
		INR 3,000
	(Non-participants:Spouse/Parents etc.)

		USD 600
		USD 300
		USD 200
	(Non-participants:Spouse/Parents etc.)

Organization Name*

(3 - 25 characters)

Address 1*

Address 2

City*

Phone*

("0-9", "-", "+", " ")

Contact Person*

Country*

Email*

(6 - 25 Characters)

Payment Details :-
Sponsorship Schemes	Amount (USD)	Amount (INR)
	USD 12,500	INR 5,00,000
	USD 8,750	INR 3,50,000
	USD 5,000	INR 2,00,000
Applicable Conversion Rate to INR (1 USD = 50.00 INR)

Mode of Payments

Note:-

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