AMBICON 2022

AMBI Membership No.

Department / Specialization*

Name of the Institute*

Address of the Institute*

Name of the Medical Council + Registration Number

Contact No*

Are you attending

(Request of choice of Workshop base on 'First Come First Served' basis. If there is no vaccancy, the same will be intimated and another workshop of similar choice will be allotted)

Pre-Conference Conference
Towards Pre-Conference and Conference

Are you attending

(Request of choice of Workshop base on 'First Come First Served' basis. If there is no vaccancy, the same will be intimated and another workshop of similar choice will be allotted)

Conference

Accompanying person
Spouse Childern below 12 Childern below 6

If yes, Specify in the order of preference (1,2,3)

Registration Amount*

Transaction Details

Name of the bank*

Branch Name*

Transaction ID*

Amount Transfered*

Date of Transaction*

Upload Transaction details(Only PDF,JPG,PNG files are allowed. File size less than 2MB)*

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		Early Bird (Till 15th June 2022)	After 15th June 2022
AMBI-Life members		10000/- + GST	12000/- + GST
Post graduate student	Towards workshops only	5000/- + GST	6000/- + GST
Post graduate student	Towards workshops & conference	8000/- + GST	9000/- + GST
Spouse		4000/- + GST	5000/- + GST
Children	Below 12 years	1500/- + GST	1500/- + GST
Children	Below 6 years	Nil	Nil
Mode of payment : Canara Bank, Jayadeva Institute Cardiology Complex, Jayanagar, Bangalore-560059 Bank Account Name : AMBI-2022 CONF Account Number : 110039126069 IFSC Code : CNRB 0008414 MICR : 560015169

Registration Details

Transaction Details