Registration Form

ICAS 2015

2nd International Conference on

Audiological Sciences

September 10-12, 2015

Sanjeevani Hall, KMC Hospital
Attavar, Mangalore, India

Registration Name:
Information Designation:
College (if student):
Address (official):
Address (Permanent):
RCI registration no (if available):
City, State, Zip:
Country, if other than India:
Telephone, e-mail address:
Registration
Mode of Payment*:
fee

Amount:

*Note:
For NEFT payment, please remit the registration fee to:
Account name: KASTURBA MEDICAL COLLEGE,
Account No.: 001401010468,
ICICI Bank LTD, MANGALORE BRANCH, MANGALORE. IFSC No: ICIC0000014.
Demand Draft (in favour of KASTURBA MEDICAL COLLEGE, payable at
Mangalore).
Name of the Bank and Branch:
DD No. and Date:
Place:
Date:

Signature of Participant

Important:
1. Completed registration form along with DD (if applicable) should be sent to organizing secretary.
Address: Mr. Rajesh Ranjan
Organizing secretory, ICAS 2015
Dept. of Audiology and Speech Language Pathology
Kasturba Medical College (Manipal University)
Attavar, Mangalore - 575001, Karnataka, India.
2. The participants who pay through NEFT shall e-mail the filled application form along with payment
details to: icas.mangalore@gmail.com.

Organized by: Department of Audiology and Speech Language Pathology, Kasturba Medical
College, Mangalore.