|
GENERAL INFORMATION: |
| |
|
Full Name*
: |
|
|
Email*
: |
|
|
Current Position*
: |
|
|
Affiliation* : |
|
|
Sex: |
Male |
Female
|
|
Postal Address: |
|
|
City: |
|
|
State: |
|
|
Country: |
|
|
ZIP/PIN Code: |
|
|
Phone: |
|
|
Cell Phone: |
|
|
Fax: |
|
|
Date of birth: |
Date |
Month |
Year |
|
Place of birth: |
|
|
|
|
FOR
FOREIGN NATIONALS: |
|
|
|
Nationality: |
|
|
Passport Number: |
|
|
Date of issue of passport: |
Date |
Month |
Year |
|
Place of issue of passport: |
|
|
Expiry date of passport: |
Date |
Month |
Year |
|
Anticipated date of arrival in India: |
Date |
Month |
Year |
|
Anticipated date departure from India: |
Date |
Month |
Year |
|
|
|
OTHER INFORMATION: |
|
Submitting ABSTRACTs |
Yes
|
No
|
|
Attending QGP School: |
Yes
|
No
|
|
Applying for Financial Support: |
Yes |
No |
|
|
|
Number of Accompanying persons: |
|
|
|
|
PAYMENT: (1)
REGISTRATION FEES: |
|
|
|
|
|
|
|
PAYMENT: (2)
ACCOMMODATION BOOKING |
|
|
|
Arrival at
Jaipur: |
Date |
Month |
Year |
|
Departure from
Jaipur: |
Date |
Month |
Year |
|
Hotel Requested
for
nights in the Hotel: |
|
|
Deposit for One
Night: US $ |
|
|
|
TOTAL PAYMENT |
|
|
|
|
|
Please make your payment by one of the
following methods: |
BANK TRANSFER:
| Beneficiary's Bank: ICICI
Bank |
|
Bank Address: ICICI Bank,
AC-4, Sector-1, Kolkata-700064 |
| SWIFT Code: ICICINBBNRI |
| Beneficiary's Account No.:
030501001141 |
| Please indicate: YOUR NAME
and QM2008 |
| After actual payment, kindly
send an email to
qm2008@veccal.ernet.in
with the Bank Transfer details
(Date and your Bank name) for
confirmation. |
|
|
|
CHECK / BANK DRAFT / MONEY ORDER:
| Payable to:
QUARK MATTER 2008 |
| Mailing
Address: |
|
Convener, Quark Matter 2008 |
|
Variable Energy Cyclotron Centre |
|
1/AF Bidhan Nagar |
|
KOLKATA - 700064, India |
| After sending the
check/draft/money order, kindly
send an email to qm2008@veccal.ernet.in
with the details (No. and Date
of issue) for confirmation. |
|
|
|
PAYMENT UPON ARRIVAL
| Late Registration fee will
be applicable. |
|
|
|
|
MESSAGE TO THE ORGANIZERS:
|
|
|
|
| |
