Registration Form for RI District Conference Probaho

REGISTRATION FORM
No. :
Continuity of Service above Self to the Mankind
R. I. District 3291 Conference 2015
Swabhumi, E. M Bypass, Kolkata
10th & 11th January, 2015
PP Rtn. Dr. Gautam Bhattacharjee
Rotary Club of Tollygunge
Chairman,
Rotary International District 3291 Conference 2015
Sir,
Please register me/us for the R. I. District 3291 Conference 2015
Name
:
Current Year Assignment
:
Name of Spouse
:
Name of Guest
:
Rotary club of
:
Meal preference
:
Total No. of Registration
:
□ Vegetarian
□ Non-Vegetarian
Enclosed : Cash/Cheque favouring “R.I.D 3291 A/c. District Conference 15”
for Rs.
(Rupees
only).
Cheque No. :
Dated :
Bank :
Branch :
CHARGES :
Rotarian
Spouse/Rotaract/lnteract
Guest
Upto 3rd January 2015
Rs. 2000/Rs. 1800/Rs. 2000/-
After 3rd January 2015
2200/2000/2200/-
REGISTRATION
1.
2.
3.
4.
DG's Office : 315 Kamalalaya Centre, 156 A Lenin Sarani, Kolkata – 700 013; Mobile : 94332 83675, 83350 27567
PDG Rtn. Swapan Mukherjee : 18/50 Dover Lane, Shubham Apt., Kolkata – 700 029
PP Rtn. Ajoy Kumar Law : Lahabari, 50A Kailash Bose Street, Kolkata – 700 006; Mobile : 98300 07991
PP Rtn. Ashim Guha Roy : Prakash Bhawan, Salt Lake; Mobile : 98300 92337
Conference Kits will be available if the Registration is made on or before 7th January 2015
RECEIPT
No. :
Name of Delegate(s) : ......................................................................................................................................................................
Rotary Club of : ................................................................................................................................................................................
Total Registration paid Rs. .................................... for .............................. person
Cash/Cheque No. ........................................................ dated ........................................ Drawn on ..................................................
Individuals :
Couples :
Date ..................................
Guests :
Interactors/Rotaractors :
Authorised Signatory
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