DELEGATE ADVANCE REGISTRATION FORM
          
Title * :
Name * :
Org/Employer * :
Designation * :
Address * :
City * :
State * :
Nationality * Indian Others
Zip * :
Tel/Mob No * :
E-mail * :

Note: If you are Foreign Delegate Please fill your passport details as it will be required for the clearance from External Affairs
Name as written in Passport * :
Passport No * :
Passport Validity * :
Place of Issue * :
Date of Birth * :  
Country * :
Other Country (if not in the list) :
SPG Member *  
SPG  Membership No.  
Enter code as shown in image *   *
PAYMENT DETAILS
DELEGATE
 
Registration Indian Delegates Overseas Delegates
SPG Members Non SPG
Members		 SPG Members Non SPG
Members
Advance (upto Dec 1 2011) Rs. 9,000/- Rs. 10,000/- US$ 300 US$ 350
On the Spot Rs. 11,000/- Rs. 12,000/- US$ 400 US$ 400

SPOUSE DELEGATE

Registration Indian Delegates Overseas Delegates
Advance (upto Dec 1 2011) Rs. 7000/- US$ 200
On the Spot Rs. 9000/- US$ 300

 
Amount
DD no/Money Transfer No  
Bank Name     
Date on DD/ Money Transfer
Demand Draft should be in favour of “SOCIETY OF PETROLEUM GEOPHYSICISTS ” payable at Dehradun
SPG Account Details:
State Bank of India, Tel Bhawan, Dehradun-248003
Account No: 10392857112
Swift Code : SBININBB156
RTGS Code: SBIN0001576
Demand Draft should be sent to:
The Secretary
Society of Petroleum Geophysicists
1, Old CSD Building, KDMIPE Campus
Kaulagarh Road
Dehradun – 248001
Uttarakhand, India
      

fields marked with * are mandatory

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