/9 thANNUAL SHORT COURSE IN CLINICAL RESEARCH METHODOLOGY

22nd and 23rd August, 2015CRSAND DAE-CTC

Registration form

Name as on certificate: Prof/ Dr/Mr/Ms _(In BLOCKLETTERS)

Qualification: Medical Council Reg No. (State/Year/No:) _

Department: Designation: _

Address:

Mobile No: "Anyother Tel No: _

E-maiIId: (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 or support from institute).• Registration fees should be paid by cash in person or sent by Demand Draft / Cheque to:

Ms. Meenakshi/ Ms. Shraddha, Conference Coordinator, Clinical Research Secretariat, Tata MemorialHospital, Parel, Mumbai 400012

• DD/Cheque should be in favour ofTMH 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 14th August, 2015. 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 em ail 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 speakers8. 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 August 20159. For queries, please call Ms Meenakshi/Ms. Shraddha- Ph: 022-24177000 Ext. 4254 or mail us at

crmworkshop@gmail.com

TATA MEMORIAL HOSPITAL, ERNEST BORGES MARG, MUMBAI 400012TEL +91-022-24117000 EXT: 4254 FAX: +91-022-24168604