Registration form

REGISTRATIONEarly bird Registration* Before Nov 30, 2011 Before Dec 30, 2011

Student INR 1000 INR 2000 INR 3000

Professional INR 2000 INR 3000 INR 5000

From Industry INR 3000 INR 5000 INR 7000

Workshop INR 1000 INR 1500 INR 3000

Enclosed Rupees ___________________________________________

__________________________________________________ (in words)

Rs.__________________________(in figures) through Demand Draft /

Cheque drawn in favour of “Pharmanext” payable at Delhi.

Name of the Bank___________________________________________

D.D./Cheque No. ___________________Dated __________

Place ___________ Date :_______ Signature ____________ Registration is non refundable and non transferable. ( No refund in case of cancellation. Only registered delegates will be allowed to attend the conference)

Please send the form along with the relevant details to:

ENQUIRIES & DETAILS

Please tick

S. No.

Pre Conference Workshop

Accomodation interested

Mr. aayush Agarwal : 8141800084Mr. Chintan Oza : 9427801975Mr. Harish Pal : 9818455437

Email: pharmanextahmedabad@gmail.com pharmanext@hotmail.com

L. J. Institute of Pharmacy Nr. Nagdev Mandir, Sanand-Sarkhej Circle, S G Road, Ahmedabad - 382210 (Gujarat)

Contact : 8141800084/9427801975/9818455437Email : pharmanextahmedabad@gmail.com,

www. pharmanextahmedabad.com, www.pharmanextworld.com

Cell

Phone Numbers with STD code

Pin Code

Pin Code

“Innovation in Pharmaceutical Industry: From Drug Development to Distribution”

National ConferenceJanuary 28-29, 2012

Organized by

PharmanextTM L. J. INSTITUTE

OF PHARMACY AHMEDABAD

In Association with Supported by

Gujarat Technological University (GTU) B.V. Patel PERD Center

Bank TransferBank Name : ICICI BANK LIMITED

Branch : B 78, Defence Colony, New Delhi -110024, India Account Name : PHARMANEXT

Account Number : 630005008543Swift Code : ICICINBBCTSIFSC Code : ICIC0006300

REGISTRATION FORM

* Early bird registration is applicable before October 30, 2011.