REGISTRATION FORM (IWCIA 2015)

    First name: 
    Middle name:
    Surname(s):

    Gender:
    Dietary Preference: Vegetarian / Non-Vegetarian

    Paper ID: 
    Paper Title: 

    Current position:
    Institution: 
    Department: 
    Address: 
    Postal code: 

    Country:
    Nationality: 

    Phone Number (optional): 
    Mobile Number (optional): 

    E-mail: 

    Accommodation required at ISI Guest House:  Yes / No
    (This will be against payment directly to the guest house
    and is not included in the registration fee. This will 
    be allotted on a first-cum-first-served basis.)

    To share a room with IWCIA participant:  Yes / No

    Arrival date: 
    Departure date:

    Registration Category: A/ B/ C/ D

    Registration Amount: 

    Mode of Payment: Wire Transfer / Demand Draft / Net Banking  
    Payment Date: 

    Any other info: