DERMACON 2016

Coimbatore, Tamil Nadu, India

th

44 National Conference of Indian Association of Dermatologists, Venereologists & Leprologists (IADVL)

st
th
Venue: CODISSIA, Coimbatore
Date: 21 to 24 January 2016

Registration Form

For office use only

.
Registration No............................
Date: ...........................................

(FILL IN CAPITAL LETTERS)

PHOTO
(compulsory)

Amount: .....................................
Receipt No ..................................
Registration Category:
IADVL Member

Conference

Non IADVL Member

Conference and CME

PG Student (PLMs)

Foreign

SAARC Country

Medical Council Registration Number: .............................................

Title:

Prof.

Dr.

Mr.

Ms.

Mrs.

Name...............................................................................
Delegate with physical disabilities

Yes

Accompanying Person

State: ............................

IADVL Membership No...........................

Age

No if yes any special need

Veg

Non Veg

Wheelchair

Others

.....................................................................................................................................................
Address.....................................................................................................................................................
City.......................................... Pin Code.............................State...............................Country..................
Phone (with STD/ISD Code).................................................Mobile........................................................
Email.......................................................................................................................................................
Accompanying Persons:
1. Dr./Mr./Ms./Mrs.............................................................

Age

Veg

Non Veg

2. Dr./Mr./Ms./Mrs.............................................................

Age

Veg

Non Veg

3. Dr./Mr./Ms./Mrs.............................................................

Age

Veg

Non Veg

4. Dr./Mr./Ms./Mrs.............................................................

Age

Veg

Non Veg

Registration Fees:
Category
IADVL Member
Non IADVL Member
PG Student (PLMs)
Accompanying Person
Foreign Delegate
Foreign Accompanying Person
SAARC Country Delegate
SAARC Accompanying Person

Early Bird Up
to 31st July 2015
Conference
Conference
& CME

1st August 2015

to 15th December 2015
Conference
Conference
& CME

From 16thDecember 2015

And Spot Registration
Conference
Conference
& CME

Rs. 7000
Rs. 10500
Rs. 4000
Rs. 4000
US $ 450
US $ 300

Rs. 9000
Rs. 13500
Rs. 6000
Rs. 6000
US $ 550
US $ 400

Rs. 9000
Rs. 13500
Rs. 5500
Rs. 5500
US $ 550
US $ 400

Rs. 11000
Rs. 16500
Rs. 7500
Rs. 7500
US $ 650
US $ 500

Rs. 13500
Rs. 20000
Rs. 7000
Rs. 7000
US $ 650
US $ 500

Rs. 15500
Rs. 23000
Rs. 8500
Rs. 8500
US $ 750
US $ 600

US $ 150
US $ 100

US $ 200
US $ 150

US $ 250
US $ 150

US $ 300
US $ 200

US $ 300
US $ 200

US $ 350
US $ 250

Registration includes service tax 12.36% and 15% IADVL share

Mode of Payment:

Cheque

DD

Cash

Bank Transfer

Credit/Debit Card

Cheque/DD to be drawn in favour of CBE DERMATOLOGY ASSCN AC DERMACON 2016 Payable at Coimbatore

Cheque/DD No.

Dated

Drawn on

Total Amount

For online registration please visit our website www.dermacon2016.com

Payment Details of Bank Transfer for DERMACON 2016 Coimbatore
Name of Account: CBE DERMATOLOGY ASSCN AC DERMACON 2016
Account Number: 058701001484, Type of Account: Savings Account, IFSC Code: ICIC0000587
Bank Name: ICICI Bank, Branch: Coimbatore Avinashi Road Branch
*Important Note: Kindly Email us a copy of Bank Transfer Confirmation Slip to info@dermacon2016.com and
Payment through Credit/Debit Card (Last 4 digits of no. . .........................) and for Bank Transfer, Name of the
Bank: ................................................................. Bank Transaction ID: .........................................................
Cancellation/Refund policy for DERMACON 2016 Coimbatore
th

Upto 30 June 2015

75% Refund

Upto 30th Sept. 2015

50% Refund

Upto 15th Dec. 2015

After 16th Dec. 2015

25% Refund

No Refund

Signature: ............................................................................................. Date: .........................................................

Instructions and Guideline for DERMACON 2016 Coimbatore

1. All the delegates to send photo (for use on ID card) along with registration form.
2. Registration is mandatory for all including faculty.
3. Delegate from India who is not a member of IADVL should provide degree certificate or copy of MCI registration.
4. PG Students must submit a confirmation letter from the HOD.
5. Non PLMs post graduate students will be considered as non IADVL members for registration.
6. Children below 5 years will not to be charged any fee.
7. Outstation cheque will not be accepted after 15th December 2015.
8. Online registration will be available up to 15th December 2015.
9. Only Cash/Card Swipe/DD will be accepted for spot registration at the venue.
10. Delegate kit is not guaranteed for spot registration.
11. Refund will be payable only after completion of the conference.
12.Separate space will be provided for codelegates and they will not allow entering the scientific hall.

DERMACON 2016 CONFERENCE SECRETARIAT

Dr. Reena Rai, Organizing Secretary
Dept. of Dermatology, PSG Hospitals, Peelamedu, Coimbatore-641004, Tamil Nadu, India
Website: www.dermacon2016.com
Email: info@dermacon2016.com
For more information please contact: +91 9025583032