COGNATHICS COORG 2013

REGISTRATION FORM
Name:.
Designation: Specialty:
Address:

PIN:

Mob:

Tel:........................................................

Email:.
Attestation from HOD:..
REGISTRATION FEE
Student delegates

Without accommodation:
With accommodation on sharing basis (first come first serve basis)
o Female delegates:

Rs.1250
Rs.1750

(Hostel accommodation for first 70 delegates)

o

Male delegates (for first 24 delegates):

Rs. 1750

Delegates:

Rs. 2000
ACCOMMODATION

Hotel rooms (on twin sharing basis)

Rs. 500 per person/ day onwards

Homestays (on twin sharing basis)

Rs. 1500 per person / day onwards

Gala dinner only

Rs. 750

Note: Please tick the appropriate. DD in favor of COGNATHICS 2013, payable at Virajpet, Coorg. Completed registration
forms along with DD should reach before 12-09-2013 to Organizing Secretary, Cognathics-Coorg 2013, Coorg Institute of
Dental Sciences, Virajpet, Coorg Dt, Karnataka 571218.
DD amount.

DD No..

QUIZ-WITH PRIZE WORTH Rs.15,000

Note: For PG students only (one team per college consisting of two students only). Interested participants must email to
cognathics2013@gmail.com with participant details before 08-09-2013.
Signature of the Delegate
Please address your registration communication to:

Please address your accommodation queries to:

Dr. Suhailuddin- +919480196581

Dr. Sajai - +918762987723

Dr. Himanshu- +919686875971

Dr. Riyas - +919448632373