Personal Information of the Participant

[Please complete this form andsend it to the Symposium secretariat by e-mail () or by fax.]

Personal Information Of the Participant

Please type or print clearly in CAPITAL LETTERS.

Title: [ ]Mr. [ ]Mrs. [ ]Ms. [ ]Prof. [ ]Dr. [ ]Others (Please specify:______)

Full Name: ______

Function at conference:[ ] AcademicDelegate [ ]Student Delegate[ ]Industrial Delegate

University/Organization: ______

City: ______Country: ______

Telephone: ( )______Fax: ( )______

Email: ______

Manuscript Identification Code______

Registration Fees

Registration Fee

Before Aug 30, 2012

After Aug 30, 2012

For Indian Delegates

All bank charges will be to the senders account.

Registration Fee for the Participant: ______

Registration Fee for students: ______

Registration Fee for accompanying persons: ______

Print full name of guest(s): ______

Total Amount: ______

Money Transaction Narration Details ______

______

Date ______Signature of the Participant ______

NOTE: For each registration, a maximum of two papers can only be accepted for inclusion in the symposium. Delegates with more than two papers are required to register twice.

PAYMENT METHOD

1. In the form of Demand Draft (A/C payee) drawn in Favor of “PFAM-21” payable at IIT Guwahati (code: 14262).
2. Online bank transfer/cash deposit through Core Banking..

• Please mention the Transaction Narration during the Money Transfer.
• Any bank charge is to be borne by the depositor.

1. All bank charges is to be borne by the depositor.
2. Please send the receipt of the money transfer to the symposium secretariat by e-mail

Please complete the form and send by e-mail to the Conference Secretariat. Should you have any questions, please do not hesitate to contact us.

E-Mail:Phone:+91-3612582668Fax:+91-361-2582699

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