Registration Form
Please fill all required details carefully. Fields marked with
*
are mandatory.
Conference Registration Details
Membership Details
1) Are you a Member of IPA?
*
Yes
No
Write Membership No.
2) Title (Please tick as applicable)
*
Dr.
Prof.
Mr.
Ms.
Mrs.
Personal Information
3) Last Name / Surname
4) First Name
*
5) Middle Name
6) Photo
*
7) Designation
8) Organisation
9) Address (Org.)
10) Date of Birth
*
11) E-mail
*
Address & Contact Details
12) Correspondence Address
*
13) State
*
14) Town / City / District
*
15) Pin Code
16) Phone
17) Mobile
*
Registration & Accommodation
18) Registration type (Check in for the appropriate option)
*
Students — Rs. 1200
Metro Students & IPA SLM — Rs. 1000
Faculty — Rs. 1500
Industry — Rs. 2000
19) Pre-book Accommodation
*
Economy (Triple sharing) — Rs. 1000
Average (Double sharing) — Rs. 1500
Luxury — Rs. 5000
None
Select Check-in dates for your stay
1 November
2 November
3 November
Payment Details
Kindly transfer the amount in "Indian Pharmaceutical Association U.P. State Branch" Bank A/c No. 162902000000296, Bank Name: Indian Overseas Bank, IFSC: IOBA0001629 through NEFT or bank deposit and upload the slip here.
Upload Slip
*
20) Amount (in words)
21) Rs (in figures)
Submit