GENERAL INFORMATION
Name *	:
Institute/ Hospital *	:
Postal Address *	:
City *	:
Pincode *	:
State *	:
Country *	:	Select One Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Union of the Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of Congo Denmark Disputed Territory Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Federated States of Micronesia Fiji Finland France French Guyana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Iraq-Saudi Arabia Neutral Zone Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyz Republic Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Occupied Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena and Dependencies Saint Kitts & Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and Islands South Korea Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United Nations Neutral Zone United States United States Minor Outlying Islands Uruguay US Virgin Islands Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe
Email ID *	:
Residence Tel. (with area code)	:
Office Tel. (with area code)	:
Mobile *	:
Fax	:
REGISTRATION TYPE
Registration Type *	:	--Select One-- Non Residential Package
Category Type *	:
Till Date*	:
Registration Amount ( )	:
Accompanying Persons Name 1	:
Accompanying Persons Name 2	:
Name of the participant with whom you would like to share aroom
Meal Preference	:	Vegetarian   Non Vegetarian
MODE OF PAYMENT
Mode of payment *		Select Cheque/ DD No Online Payment

Cheque/ DD Favouring 'ASSICON 2012 NEW DELHI' payable at New Delhi.

Note: Airport transfers are not included in the package.

Please send duly filled registration forms along with DD/Cheque to:
Conference Secretariat, ASSICON- 2012
C/o Indian Spinal Injuries Centre
Sector-C, Vasant Kunj-110070
New Delhi, India
Tel: 011-42255356, 42255243

* Hotel Check in 2.00 pm, on Feb 23 hotel check out 12.00 pm, on Feb 26: Possibility of earlier check in from 10.00 am onwards with prior intimation.

** Children above 12 yrs of age will be considered as adult accompanying person

*** Procedure available on website.