REGISTRATION FORM

IACI – 2017 Mumbai
Annual IACI Congress
On 14th, 15th & 16th September 2017

Account details for online payment
Account Name: INDIAN ASSOCIATION OF CARDIAC IMAGING
A/c No. : 912020060730871
IFSC Code: UTIB0000061
Bank Name: AXIS BANK LIMITED, DHIRAJ BAUG, LBS MARG, THANE (W) 400602
Demand Draft in favour of “INDIAN ASSOCIATION OF CARDIAC IMAGING”

FEES: Please tick appropriate box or boxes (REGISTRATION FEES NON REFUNDABLE) (Please PAY conference & workshop fees separately, only workshop registration not allowed)

Life Members
Consultant 3500/-
Resident 2000/-
Non Life Members Only Conf Conf+Life Members
A. Radiologist (Free entry to Any One Workshop)
Resident Doctors 2999/- 3750/-
Consultant
4999/- 6999/-
B. Non Radiologist
Cardiologist / Physician /
Nuclear Physicist & Other
2000/- 2999/-
C. Medical Technologist 1900/- (Conf. + Workshop)
D. International Delegate $90 $150
Workshop Registration (Extra): Any One - 1500/- Any Two - 3000/-
Workshop Registration (International Delegate): Any One - $50 Any Two - $100

(for online payment)

Mailing address for Registration:
Mrs.Trupti Palkar
Administrator
Indian Association Of Cardiac Imaging
Registered Office: Infinity Medical Centre Citi Tower, Ground Floor, Next To MGM Hospital,Parel(East), Mumbai-12.
Cont no.9833347481
Website: www.iaciind.org , wwww.iacimumbai2017.com