Want create site? Find Free WordPress Themes and plugins. Registration Form 1 Personal Information2 Membership Detail3 Registration Fee4 Checkout Title*Dr.Prof.Mr.Mrs.MissName* First Last Age*Sex*MaleFemaleAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Phone*Email* Registering as*GSI/ROS/JOS MemberNon Member OphthalmologistResidents/Fellows/TraineesTrade DelegateGuest FacultyGSI/ROS/JOS MemberGSIROSJOSGSI Membership Number*ROS Membership Number*JOS Membership Number*Accompanying Person*YesNoAccompanying Person with Guest Faculty*YesNoAccompanying Person's Name* First Last Accompanying Person's Name (with Guest Faculty)* First Last Registration Fee* Price: ₹ 4,000.00 Registration Fee* Price: ₹ 5,000.00 Registration Fee* Price: ₹ 2,800.00 Registration Fee* Price: ₹ 5,500.00 Registration Fee* Price: ₹ 4,000.00 Registration Fee - Guest Faculty* Price: ₹ 0.00 ComplimentaryRegistration Fee - Guest Faculty* Price: ₹ 0.00 Complimentary for Accompanying Person of Guest Faculty Bank Details Online Money Transfer can be done for Registration as per the following Details: Account Name: Glaukopedia Account Number: 01150100029057 Bank Name: Bank of Baroda Address: Johari Bazar, Jaipur IFSC Code: BARB0JOHARI (the fifth digit is zero) MICR Code: 302012003 The crossed Demand Draft / at par Cheque should be in favor of "Glaukopedia" payable at Jaipur, Rajasthan. Please post the completed form with DD/Cheque to the Conference Secretariat at the address mentioned below. Also send a duplicate scanned copy of the form with DD/Cheque to firstname.lastname@example.org.Complimentary Registration We are obliged to register you and your accompanying person as our Guest for Glaukopedia. Please input your Guest Faculty Invitation Code in order to register as Guest Faculty. We have already sent Invitation Code to all our Guest Faculty to their email address.Total ₹ 0.00 Guest Faculty Invitation CodeUnique IDCommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms. Did you find apk for android? You can find new Free Android Games and apps.