ASPERGERS & HIGH FUNCTIONING AUTISM

TRAINING BY TONY ATTWOOD

DVD ORDER FORM

National Centre for Autism India, Pocket 7 & 8, Jasola Vihar, New Delhi 110 025 Email: Mob: +91 98113 32254, +91 11 4059 7319, 4054 0991,

This is a fillable form. Click on the grey boxes to enter information. Press ‘tab’ to move between items. Alternately, print and fill the form with a pen.
Please use BLOCK LETTERS. Attach a copy of your demand draft / online transaction receipt. Keep a photocopy for your records.
PERSONAL INFORMATION
Prof Dr Mr Ms / First Name: / Last Name:
Father Spouse / First Name: / Last Name:
Postal Address:
State: / Country: / Pin Code:
Email: / Contact No:

National Centre for Autism India, Pocket 7 & 8, Jasola Vihar, New Delhi 110 025 Email: Mob: +91 98113 32254, +91 11 4059 7319, 4054 0991,

ORDER DETAILS
Number of copies of DVD’s required: / (Donation of minimum Rs. 1500 / DVD)
Payment Mode: / Online Bank Transfer / Demand Draft (in favour of ‘Action for Autism’ payable at New Delhi.)
Online Transaction ID /Demand Draft No: / Dated:
Drawn On Bank:
Total donation:
DVD COLLECTION INFORMATION (17 - 21 APRIL 2017)
I will collect my DVD from AFA office in Jasola, New Delhi
I want my DVD to be posted to my postal address and I will pay the shipment charges at the time of delivery.
I understand and accept that:
•I will receive the DVD for the 2 days of the workshop. Replacement of the faulty DVD will be done only within 1 week of the date DVD is received.
•The DVD is intended only for me.
•I am required to attach a copy of my receipt / demand draft / online transaction receipt along with this form.
•Incomplete order forms or forms not accompanied with the donation for the DVD will not be processed.
•The postal charges will need to be paid in cash to the person delivering at the time of delivery.
•The donation is non-refundable. It will not be possible to adjust the contribution towards registration against other services at AFA.
•Demand draft may be drawn in favour of ‘Action for Autism’ payable at New Delhi. Cheques or debit/credit cards are not accepted.
•Online bank transfer:Beneficiary: Action For AutismBank: Vijaya Bank, Defence Colony, New Delhi, India
SWIFT No: VIJBINBBDCDIFSC Code: VIJB0006005MICR Code: 110029007
Savings A/C No:Within India Transactions: 600501010009008 Oversees: 600501550010210
Completed forms may be delivered to: Trainings Coordinator, Action For Autism, The National Centre For Autism, Pocket 7 & 8, Jasola Vihar, New Delhi 110 025.
Signature

Action For Autism, The National Centre For Autism, Pocket 7 & 8, Jasola Vihar, New Delhi 1100 025 • Ph: +91 11 4054 0991-92 • Email: • URL: