ICISS'08 Registration Form



ICISS’08 REGISTRATION FORM

(Each Paper should be registered separately by at least one author)

|Personal Details |

|Name | |

|Gender | |

|Qualification | |

|Nationality |Indian |Others |

|Currently residing at (Country) | |

|Designation | |

|Department | |

|Name of the Institution/ Organization | |

|Note: |

|Indian Delegates residing in India can only make payment in Indian Rupees. All other delegates (including Indians currently |

|residing at other countries) should make payment in USD. |

|Registration Details |

|Registering as | |

|(a) Author (Please tick as applicable) |Industry |Academics |Student |

|If Author, Specify the following | |

| 1) Paper ID | |

| 2) Title of the Paper | |

|(b) Participant (Please tick as applicable) |Industry |Academics |Student |

|Address for Communication | |

| | |

| | |

| | |

|Contact Number | |

|Fax (Optional) | |

|Mobile (Optional) | |

|Contact No. (In Case of Emergency) | |

|E-mail | |

|Is Accommodation Required?* |Yes: (Hotel/Guest House/ Hostel) |No |

| | | |

|Total money enclosed |INR ………………… |USD ………………… |

|Mode of payment |Money Transfer |Credit Card |Bank Draft / Banker’s |

|(Please tick as applicable) | | |Cheque |

*Hotel booking can be done directly by the participants. The organizing committee will provide some limited number of guest house accommodation and hostel accommodation. This will be allotted based on first come first serve basis.

|Registration Details for tutorials only |

|Registering As |Student |General |

| | | |

|Total money enclosed |INR ………………… |USD ………………… |

|Mode of payment |Money Transfer |Credit Card |Bank Draft / Banker’s |

| | | |Cheque |

|Selected tutorial(s) : (Specify tutorial code) | |

|Payment Details |

|I am sending herewith Conference/Tutorial fee payable to “Organizing chair, ICISS 2008” at Hyderabad by |

|1. Money Transfer |

|I have remitted the Conference Fee Amount of USD/ INR …….……………………………through Swift (swift code: ANDBINBB; Bank: Andhra Bank, Mumbai)|

|for credit of “Organizing chair, ICISS 2008”, Bank Account Number 1034 11011001694 at Andhra Bank, JNTU Campus, Kukatpally, |

|Hyderabad – 500 072, India (Code: 1034) |

|The transaction ID is: …………………………………… dated ……………… |

|2. Credit Card |

|I hereby authorize “Account No. 1034 11011001694, Andhra Bank” to charge the Conference Fee to my credit card in accordance with |

|the details given below: |

|Credit Card Number: |Amount: |

|Name as on the card: |Type (Visa / Master card): |

|Date of Expiry: |Last three digits on the reverse: |

|PHOTOCOPY OF BOTH SIDES OF MY CREDIT CARD is enclosed herewith. |

| | |

| | |

|Date: |Card Holder’s Signature: |

|3. Bank Draft / Banker’s Cheque |

|Amount: |

|Drawn on Bank: |

|Draft / Cheque No.: |

|Dated: |

Date: Signature of the Applicant

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