Registration



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REGISTRATION FORM

COURSE DETAILS

Venue:

Vasant & Nirmal Oswal Centre for Post Graduate Training and Research, 14th Floor Superspeciality Wing, Deenanath Mangeshkar Hospital & Research Centre, Erandwane, Pune 411004

Date:

5-6 –August- 2017

Fee:

Rs.13000/- ($ 300) for Practicing ENT Surgeons

PERSONAL DETAILS

Surname




First Name




Title (Degree)




Regn. No.




Address







Postal Code




Date of Birth




Daytime Telephone




Mobile No




E-mail Id




Dietary Requirements




Are there any other requirements that you would like to make us aware of?







Do you require information about local accommodation?

Yes / No

PRESENT APPOINTMENT

Hospital




Grade




Other (Please specify)




Number of year in post




HISTORY

Have you attended any Hands on Course in Laryngology?

Yes / No

Are you familiar with the basic principles of Laryngology?

Yes / No

PUBLICITY

How did you find about this course?

Poster




Training Advisor




Tutor




Colleague




Other (please specify)


Signed - Date -


COURSE DIRECTOR

Dr. Sachin Gandhi, MS

Deenanath Mangeshkar Hospital and Research Centre Near Mhatre Bridge, Erandwane

Pune – 411 004



Phone – 020 49 15 31 14


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