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:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
|
|
|
|
|
|
___________________City:
_____________ Pin
Phone
(O): _________________ (R) ______________ Fax: __________________
e-mail:______________________________________________________________
Diet:
Vegetarian / Non-Vegetarian/ Any Special Diet: ______________________
Present
Responsibility:
___________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Qualifications:
Medical
Degree Specialty (if any) Year University
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
________________________________________________________________________________________________________________________________________
____________________________________________________________________
Work
Experience
Organization Position Years
of Experience
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Signature:
__________________ Date:__________________
Course
Fee Details
Demand
Draft Number ______________ Date:_____________Amount:_______
Name
and address of the bank on which the draft is drawn:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________