Workshop Registration Form

Online Registration Form

GURUKULAM VEDIC RESEARCH FOUNDATION

Workshop on

"AYURVEDIYA AUSHADHIKARAN"

23,24 & 25 NOV 2012

VENUE:

Shree Preetivardhan Mangal Karyalaya, Jalgaon,Dapoli,

Dist Ratnagiri, Maharashtra

(Right Click on Images to save Brochure)

Name*

First NameMiddle NameLast Name

Gender*

MaleFemale

Birth Date*

MonthDayYear

Delegate Address*

Street Address

Area

CityState / Province

Postal / Zip CodeCountry

E-mail*

Facebook ID

Mobile No*

Category*

PhysicianStudent UGInternStudent PG (Plz enter Specialization below)

PG Student Specialization

Institute Name and Address*

Name

Address

CityState / Province

Postal / Zip CodeCountry

Participating in Competitions?*

PPT Presentation Topic?*

Date and Time of your arrival to Dapoli*

MonthDayYearHourMinutesAM/PM Option

Date and Time of your departure from Dapoli*

MonthDayYearHourMinutesAM/PM Option

Will you require convey from Khed Railway Station to Dapoli*

YesNo

Payment details:

Fees:

Date	Student / Intern	Practitioners
Before 10 Nov 2012	Rs. 2000/-	Rs. 2300/-
After 10 Nov 2012	Rs. 2500/-	Rs. 2800/-

Spot Registration Rs. 3000.00

Note: Fees includes

· Registration Fees, Welcome Kit, Certificate, Morning Evening Tea and Breakfast, Lunch, Dinner, Trekking expense and accommodation from 23rd Morning to 25 Evening (3 days and 2 nights)

· However for delegates coming on 22nd and/or leaving on 25th late night or on 26th, accommodation and meals will be provided on prior intimation at an extra cost of Rs. 100/-

· Accommodation will be in 2 separate Halls for Males and Females.

For wired Transfer and Deposits

A/c Name:	THE ALCHEMY INSTITUTE
A/c No:	0176102000003575
Bank:	IDBI Bank
Branch:	Ponda, Goa
IFS Code:	IBKL0000176

For any querry:

Dr. Sameer 8087874690 Dr. Akshar 9404962904

Dr. Neha 9423015868 Dr. Abhijit 9423062463

www.gurukulamvedic.com

Email: gurukulamayurved@gmail.com