Name : __________________________________

Mailing Address : _________________________________
                            _________________________________

Name of Spouse : _________________________________

Veg : ________________ Non Veg : _______________

Telephone: ____________________Fax:___________________ E-Mail : ____________________________

Delegate fee :

Pre conference laparoscopic workshop : _________________

IAPS conference Delegate fee              : __________________

Spouse                                                : __________________

Children above 12 years                      : ___________________

One day Hotel Accommodation           : ___________________
(Mention the Hotel and the type of accommodation) or the range )

Out station Cheque add Rs.25             : ___________________

Total                                                   : ___________________

Payment to be made on Demand draft in favour of Indian Association of Paediatric Surgeons 24th annual conference Coimbatore.

DD details.

Travel plans.

Date and Time of arrival

Train                                                                               Air

Do you want to visit other places in Tamilnadu?
Please write to us in detail and we will make the necessary arrangements

Date                                                                                                               Signature