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ISACON NE 2016
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For Registered User




Registration Here



Name:
Age:
Sex:

 

ISA Membership No.:
Designation:
Type of membership:
ISA Members Non ISA Members PG Student
Associate Member Accompanying Persons

 

Address for correspondence:

 

City:
state

 

P.O.:
Pin No.:

 

Permanent Address:

 

City:
state

 

P.O.:
Pin No.:

 

Mobile No.:
Fax

 

E-mail:

 

Accompanying Person
Sl. Name Age Sex Diet
1.
2.
3.
Accommodation:
Required Not Required

 

Types of Accommodation Required:

 

Name of Hotel/Lpdge preffered:

 

Room Type:
AC Non AC SINGLE DOUBLE TRIPLE STANDARD DELUXE SUITE
Others:

 

Details of Payment:


 

Deligate Fee:
Rs.

 

Accompanying Persons:
Rs.

 

Accomodation Advance:
Rs.

 

Workshop:
Rs.

 

Any Others:
Rs.

 

Total Amount:
Rs.

 

Inword: Rupees

 

Mode of Payment: Cash/DD/ Cheque(multicity)

 

Cheque/DD No.:

 

Date of Issue.:

 

Name of the Bank:

 

Branch:

Account payee cheque/DD to made in favour of "ISA: Dibrugarh City chapter branch" payable at UBI, Assam Medical college branch. Dibrugarh.
A/C No.: -1417010106044; IFSC:-UTBI0AMHH54).


New Password:
Confirm Password :

 

 

 


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