OTICON 2013 Brochure

Registration Form
First Name ______________________________ Middle Name_____________________
Surname _________________________________________ Sex: M / F ______________
Address_________________________________________________________________
_______________________________________________________________________
City ______________________________________Pin code_______________________
State_____________________________________Country________________________
E-mail_____________________________________ Mobile _______________________
Name of the Institution (Workplace)____________________________________________
AIOTA Membership No:_____________________________________________________
No of Accompanying Person:_________________________________________________
Category of Registration:
Member / Nonmember / Student Member (UG) / Other professionals [ü]
Payment Mode: DD/ Online
Sl. No Registration Category Registration fees (Rs.)
1 Self
2 Accompanying person
Total
Accommodation Facility: Yes / No; If Yes then specify the type [ü]
Category of
room
A/c
Non A/c
Single
[ü]
Double
[ü]
Triple
[ü]
Dormitory
[ü]
Grant Total (Registration fee + accommodation fee)
No of
Person
No of
Days
Accommodati
on fees in
total