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   Cuticon 2005

Online Registration


Name
  Surname Middle name First Name
 
Age
 
Food Veg Non-Veg
 
Gender Male Female
 
Category Member Non-Member Post-Graduate Other
 
Address
 
District
 
State
 
Pin
 
Telephone ( with STD Code )
 
Email ( if any )
 
Accompanying
Persons (number)
 
Veg (number) Non-Veg (number)
 
Names of
Accompanying Persons
 
Payment Details A demand draft drawn in favour of "IJD GoldCon and Cuticon 2005" for
Rs 
D.D. No.
Drawn on (date)
Bank
will be posted immediately.

   
N.B. : Online registrations will be confirmed only after receiving the registration fee.

Mail the Demand Draft to :
      Dr. Goutam Banerjee ,
      Organizing Secretary, IJD GoldCon and CUTICON 2005,
      IADVL, WB State Branch,
      IMA House,
      53 Creek Row Kolkata-700 014,
      WB, India



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