Registration Form

Name :

Age :

Sex :
MaleFemaleOthers
Phone Number :

Email :

Address :

City :

State :

Pin :

Country :

Institute / Hospital :

PGTNON-PGT

I hereby enclosed cheque / demand draft / money transfer through net banking no. Date Drawn on in favour of “Institute of Pulmocare & Research”.

Signature :

Date :

Registration fees:

Registration till 18th May 2024: PGT: Rs. 1000/- Non PGT: Rs. 1500/- Spot registration: PGT: Rs. 2000/- Non PGT: Rs. 2000/-

Bank Account Details of the Institute

A/c Name: Institute of Pulmocare & Research, A/c No.: 31344713421, A/c type: Savings IFS code: SBIN0012360, Name of the Bank: State Bank of India Branch Address: CF Block, Saltlake, Kolkata – 700064. PAN No.: AAAAI0592E