(Please write in Block Letters) �Receipt �Number�............................................(�For �ffiO�ce use only)

(Above 70 years) (Please tick as appropriate)

*Title - Dr. Prof. Mr. Mrs. Ms. (Please tick as appropriate)

*IAP Member - Yes No *IAP Membership No.......................................................................................................................................................

PG Student Trade Delegate Foreign Delegate Sr. Citizen

*First Name:

*Last Name:

Name to be printed on Badge:

*Date of birth: _______/_______/_______ Age: ( ) Gender: Male Female Nationality:

Institute: Designation:

*Address:

*City: State: Pin Code:

Country:.............................................Phone: (With STD CODE)............................................................ *Mobile:

Email (Mandatory)

Accompanying Person Details:

*Choice of Food : Vegetarian Non Vegetarian Jain

**Female Delegate Travelling alone : assistance require to book the accommodation � Yes �No

* PG Students should submit the bona �de certi�cate from Head of the Department/Institution along with Registration form* Senior citizens need to submit their age proof** The limited accommodation option are available on payment basis and will be allotted as per the availability on twin sharing basis only

Total Paid:.................................................................................................................................................................................................................................................

Preferred mode of payment: Cash Card Net Banking DD(DD should be in favor of “PEDICON 2021” payable at Greater Noida)

REGISTRATION FORM

PAYMENT DETAILS FOR BANK TRANSFER

Account Name: PEDICON 2021

Account Number: 10051098514

SWIFT Code : IDFBINBBMUM

IFSC Code: IDFB0020154 / IDFB0040101

Account Type : Saving A/C

MICR Code: 110751035

Bank: IDFC FIRST Bank Ltd

NAMESR. NO.

Total

1

2

3

4

AMOUNT GENDER (M/F)

AGE

Please Note:-Those who are depositing registration fee amount directly in conference bank account or opting IFSC/ RTGSpayment option for the conference registration. We request them to kindly download the registration form �ll it and send us the scanned copy of the same along with the payment details either in hard or soft format, enabling us to trace it for our internal record. For registration query write us on – registration@pedicon2021noida.com

Branch: Greater Noida Branch, Ground Floor, G-5/C-1,Gautam Buddha Nagar – 201308

Organized byHosted by

GENES TO TEENS : MISSION & DREAMS58th Annual Conference of The Indian Academy of Pediatrics

1 IAP Member INR 8,000 INR 12,000 INR 14,000 INR 20,000 INR 28,000 INR 30,0002 Accompanying Person INR 8,000 INR 12,000 INR 14,000 INR 20,000 INR 28,000 INR 30,000 of IAP Member 3 Non-IAP Member INR 15,000 INR 24,000 INR 28,000 INR 40,000 INR 56,000 INR 60,0004 Accompanying Person INR 15,000 INR 24,000 INR 28,000 INR 40,000 INR 56,000 INR 60,000 of Non-IAP Member5 PG Student Registration N/A INR 5,500 INR 5,500 INR 8,800 INR 8,800 INR 11,0006 Accompanying Person N/A INR 12,000 INR 14,000 INR 20,000 INR 28,000 INR 30,000 of PG Student7 Corporate Delegate N/A INR 20,000 INR 25,000 INR 30,000 INR 44,000 INR 55,0008 Accompanying Person N/A INR 20,000 INR 25,000 INR 30,000 INR 44,000 INR 55,000 of Corporate Delegate9 SAARC Delegate $150 $150 $150 $150 $150 $45010 Accompanying Person $150 $150 $150 $150 $150 $450 of SAARC Delegate11 Non-SAARC Delegate $300 $300 $350 $400 $700 $90012 Accompanying Person $300 $300 $350 $400 $700 $900 of Non-SAARC Delegate13 IAP Senior Citizen > 70yrs Nil Nil Nil Nil INR 8,000 INR 10,00014 Accompanying Person INR 8,000 INR 12,000 INR 14,000 INR 20,000 INR 28,000 INR 30,000 of IAP Senior Citizen > 70yrs

Preferred mode of payment: Card, Net-Banking, online payment, UPI and Demand Draft- We are not accepting cheques for registration , hence do not opt this. PAYMENT MODE AS CHEQUE AND CASH DEPOSIT IN PEDICON 2021 NOIDA BANK ACCOUNT WILL NOT BE ENTERTAINED.

Only 1 registration per paytm account/mobile no/UPI/ Draft / Demand Draft would be accepted, if there are multiple registrations in 1 transfer, it would be considered as Trade Registration and fees would apply accordingly

Trade fee slab will be applicable for all the registration categories (i.e.- IAP, Non IAP, PG, Accompanying Delegate) if registration is being done by Pharma Company.

Organizers reserve the right to reject a registration if found in violation of registration rules or to reassign them to a category which they may deem fit

Registration DD should reach PEDICON 2021 Secretariat o�ce within 10days of the DD issuing date via speed post or registered post

DD should be issued from the local bank branch of the city of the delegate