10 th ANNUAL SHORT COURSE IN CLINICAL RESEARCH METHODOLOGY

28th and 29th May, 2016

CRS and DAE-CTC

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Registration form

Name as on certificate: Prof/ Dr/Mr/Ms ______

(In BLOCK LETTERS)

Qualification:______Medical Council Reg No. (State/Year/No :) ______

Department:______Designation:______

Institute/Organization:______

Address:

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Mobile No: ______Any other Tel No: ______

E-mail Id: ______(compulsory)

Date: ______Signature: ______

PAYMENT DETAILS:

Cash / Cheque / DD No.: ______Bank: ______Amount______

REGISTRATION DETAILS:

·  Registration fees: Rs 2000 (entire course); Rs 1000 (for students with letter of support from institute).

·  Registration fees should be paid by cash in person or sent by Demand Draft / Cheque to:

Ms. Meenakshi, Conference Coordinator, Clinical Research Secretariat, Tata Memorial Hospital, Parel, Mumbai 400012

·  DD/Cheque should be in favour of TMH CRM Course (please add Rs 80 for outstation cheques).

·  Online link for registration and credit payment: https://tmc.gov.in/newsnevents/event-list.htm

·  Last date for registration is 20th May, 2016. In case there is shortage of kit, ‘Spot registration’ delegates may not be issued the same.

·  PLEASE NOTE:

1.  Registrations for the course will be limited depending on auditorium capacity.

2.  All communication regarding the course will be sent only to the email address mentioned – please ensure a valid email address.

3.  Please mention the exact name as required on the certificate – no subsequent changes will be made.

4.  For medical personnel, please mention medical council registration number to earn CME points if sanctioned by MMC (application is being processed).

5.  Fees are not refundable.

6.  Lunch and tea/snacks will be provided for registered delegates.

7.  Some topics may vary depending on availability of speakers

8.  Final status of Medical Council credit points and scientific programme with lecture timings will be displayed on the website http://tmc.gov.in by 20th May 2016

9.  For queries, please call Ms Meenakshi– Ph: 022-24177000 Ext. 4254 or mail us at

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Tata Memorial Hospital, Ernest Borges Marg, Mumbai 400012

Tel: +91-022-24177000 EXT: 4254 FAX: +91-022-24168604