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Two Days Course on

Statistical Parametric Mapping2005

8-9 January 2005

Registration Form

Please return the completed form to :

Dr.K.Srinivasan and Dr.Kesavadas C

Course Coordinators, SPM 2005

Indian Institute of Information Technology and Management-Kerala,

Park centre, Technopark,

Trivandrum 695 581, Kerala.

Telephone : 91-471-527567, 700 777

Fax: 91-471-527568

Email: ksrini@iiitmk.ac.in and kesav@sctimst.ker.nic.in

Web: www.iiitmk.ac.in

 

Name:______________________________________________________________

 

Gender: Male / Female Age: Yrs.

 

Designation:_________________________________________________________

 

Organization:________________________________________________________

 

Address for Communication: ____________________________________________________________________

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Phone (O): _________________ (R) ______________ Fax: __________________

 

e-mail:______________________________________________________________

 

Diet: Vegetarian / Non-Vegetarian/ Any Special Diet: ______________________

 

Present Responsibility: ___________________________________________________________________

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Qualifications:

 

Medical Degree Specialty (if any) Year University

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Work Experience

 

Organization Position Years of Experience

 

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Signature: __________________ Date:__________________

 

 

 

 

 

 

Course Fee Details

 

Demand Draft Number ______________ Date:_____________Amount:_______

 

Name and address of the bank on which the draft is drawn: _____________________________________________________________

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