A) Registration Form

LUCKNOW CAMPUS
REGISTRATION FORM
National Symposium on “Interfacing Chemical Biology & Drug Design (ICBDD)” 24-25th Feb. 2015
Name of the Participant: Prof/Dr/Mr/Ms_______________________________________________________
Occupation: _______________________________________Age_______________Gender______________
Organization: ___________________________________________________________________________
Address: _______________________________________________________________________________
City: __________________Phone No.:__________________ Email: _______________________________
Category: Student/Research Scholar/Institution Delegate/Industry Delegate: ___________________________
Local/Outstation: ________________________________________________________________________
Broad Area: ______________________________________Poster presentation (Yes/ No)_______________
Title of the Abstract (if yes): ________________________________________________________________
Accommodation Required: ________
Payment Mode:
If Yes
Demand Draft
From ___________________ To _____________________
Cheque
Online payment
Cash
Payment Detail: Paid Amount___________ DD No/Cheque No.______________ Dated:__________
Bank Name (withdrawn from):______________________ Branch _________City____________Zip Code
Details for Online payment:
Name of Bank: Axis Bank Limited
Account No. 053010100284066
Type of Account: Saving Account
IFS Code: UTIB0000053
SELF DECLARATION
I, Prof./Dr./Ms./Mr.__________________________ declare that paper entitled _________________________
________________________________________________________________________________________
is my original research work which has not been published or sent for publication anywhere.
Date ________
Place ________
Signature___________________
Name______________________
*Please send this form along with the demand draft at the following address:
Prof. (Dr.) Devdutt Chaturvedi
Convenor ICBDD-2015
Amity Institute of Pharmacy, Amity University Uttar Pradesh(AUUP), Lucknow Campus,
Malhaur (Near Railway Station), Gomti Nagar Extension, Lucknow-226028 (U.P.)
** Soft copy of duly filled form can be mailed at: [email protected]
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