All fields marked with * are mandatory.
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My Name Dr.
*
My Preferred Mailing Address :
( Clinic / Residence )
My Tel.No (with STD Code) Clinic:
My Tel.No (with STD Code)Residence:
*
My Mobile:
*
My Email ID:
*
My Qualification:
My Website:
I am in Academics / Clinical Practice for ( in years ) :
I am with Organisation / Institute
( if any ) :
*
I would like to do the 3 day Hands-On course:
At Thane
At New Delhi
*
Dates for the Hands-on Course:
*
My Mode Of Payment :
Cheque
DD
Cash
Confirm dates by SMS OR A Call before sending payment
( OUTSTATION PAYMENTS BY DEMAND DRAFT OR BY AT PAR CHEQUES OR BY CASH ONLY )
*
My CHEQUE / DEMAND DRAFT NO. :
*
Dated:
*
for Rs.
*
of Bank
Branch:
My colleague has recommended this hands-on CDE programme
Colleagues Name :
Mobile :
I have previously attended
Dr. Rajiv Verma’s Presentation at :
Date :