Sankara Nethralaya Invites You For Unique Contact Lens Workshops

“Unique Contact Lens Workshops”
Registration Form
Name
Institution / Practice Name
Professional Qualification
Address
: _______________________
: _______________________
: _______________________
: _______________________
: _______________________
Contact No.
Email
: _______________________
: _______________________
Name of the workshop which you want to register for
(Each workshop Rs. 500/-)
Please tick
1. “Trouble shooting and problem solving in current contact lens practice” – 14 th July 2013
2. “Learn more on contact lenses – Specialty contact lens fitting ” – 1 st September 2013
3. “Reducing dropouts and making a profitable practice” – 10 th November 2013
Mode of Payment
NEFT / DD Details
Date:
Payment details
: NEFT / DD / Cash
: Bank ______________________
Date ______________________
Amount Rs. 500 /1000 /1500
DD / NEFT Ref. No.__________
Address
Payment mode can be cash payment in person, DD or NEFT.
Demand Draft - In favour of Medical Research Foundation, Chennai
NEFT – MEDICAL RESEARCH FOUNDATION
STATE BANK OF INDIA
A/C NO: 10497528701
IFSC CODE: SBIN0001176
NUNGAMBAKKAM BRANCH
*** Kindly send the transaction details of NEFT to our mail id.
Contact lens dept.
Medical Research
Foundation
No. 18, College Road
Chennai – 600 006.
Mob. No. 9384853003