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- REGISTRATION FORM -

Savitribai Phule Pune University, Pune Sponsored

Two Days National Conference on 'Ethnomedicine: Prospects and Challenges in Global Healthcare Scenario’ & National Level Paper Presentation Competition 10th ‘INDIRA PHARMA ZEAL’ On 21st & 22nd February 2018 1. Full Name : __________________________________________________________ (Surname) (First) (Middle)

2. Class

: _____________________________________________________

3. Institution

: _____________________________________________________

4. Address : for Correspondence

_____________________________________________________ _____________________________________________________

Mobile

: ___________________ Email: __________________________________________

5. Abstract Submission for : Poster Presentation 6. Registration Fee:

Oral Presentation

Dates Registration* on or before 20th February 2018

Student

Faculty

Rs. 300

Rs.450

* Spot registration will also be available ( Demand draft drawn in the favor of, “Principal, Indira College of Pharmacy”, Payable at Pune.) .

The DD should be submitted in person on 21st February 2018. The Scanned copy of the DD should be sent / Mailed along with the registration form.

Note: 1.Photocopy of the registration form may be used.

2. The Scanned copy of the DD should be sent along with the registration form.

3. A single DD for multiple delegates from the same institution will be accepted

Please e-mail this dully filled form on or before 20th February 2018.

Email: adminicp@indiraicp.edu.in Accommodation Required

Date: ___________

Yes

No

Signature of the Participant

REGISTRATION COMMITTEE 1. Mr. Amir Shaikh +919881785923, 2. Mr. Sunil Kakad +919970969085, 3. Mrs. Meghana Dabhadkar +918308020900