The 7th Annual Parekh Indo –US Foot and Ankle Conference. 8, 9, 10 January2016

Registration Form: INDO-US FOOT AND ANKLE COURSE 2016, Ahmedabad

Note:- Allowed file Types[".jpg,.png,.gif,.jpeg,.pdf"]
Registration as:
1) Surname:
2) Name:
3) What way you want print on badge:
4) Address / Landmark for correspondence:
5) City:
6) State:
7) Country:
8) Pin/zip:
9) Mobile No:
10) Email:

11) Repeat Email address:
12) A. Alternate email address:
B. Have you submitted abstract online for e Poster?
13) A. Are you a Gujarat Orthopaedic Association member? Yes No
B. Are you an Indian Orthopaedic Association Member? Yes No
14) Are you a PG Student or Resident?– upload Image file of Certificate from HOD. Yes No
15) Mode of Payment done: (tick and fill anyone from A to D):
(1) Beneficiary Account Name: ‘Indo-Us Foot and Ankle Course 2016 ‘
(2) Beneficiary Account Number at State bank of India: 35009244451
(3) Beneficiary Account IFSC:SBIN0060399
(4) MICR: 380002125