B O S S U M M I T 2 0 1 8 Bossummit with a difference Under the aegis of KOS Name*: ______________________________________________________________________________________________________ Age: ___________ Sex: M F Hospital / Instuon: ________________________________________________________________________________________ Mailing Address: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Mobile No*: ___________________________________ Email*: _______________________________________________________ BOS Member KOS Member Membership No._________________ Others Fellow / Post Graduate KMC / Other Medical Council No*: _______________________________________ Food Preference: Veg Non-Veg *Mandatory fields to be filled Please find enclosed Rs.__________________________, in words ________________________________________________ By Cheque/DD No.______________________ dated ______________ drawn on ___________________________________ Signature of Parcipant REGISTRATION FEES Early Bird up to April 30th, 2018 Late Fee up to June 5th, 2018 Spot Registraon BOS / KOS Members / Others ` 3,000 ` 3,750 ` 4,250 PG / Fellows ` 2,000 ` 2,500 ` 3,000 • PG / Fellows: Letter from HOD / Institute and acopy of ID Card is necessary • Registration Fee includes Delegate Kit, Admission to Scientific/Trade Exhibitions, Lunch and Coffee • Spot Registration Delegates are NOT ELIGIBLE for CME Credit Hours (New KMC rules) • CME Credit Hours subject to attendance of entire programme for 2 days • Certificates will be issued at 5.00 pm only to delegates who register before June 5th, 2018 • No refunds will be made for cancellations • Use one form for each registration 23rd and 24th June, 2018, ITC Gardenia, Bangalore For queries contact: 9342935370 / 9591001482 [email protected] / [email protected] MODE OF PAYMENT • DD / Cheque in favour of “Bangalore Ophthalmic Society” • Through website: hp://www.bangaloreophthalmicsociety.org (kindly send us an email to [email protected] with transaction details and bank name, so that the transaction can be tracked. Please mail the completed Registraon Form along with DD / Cheque to: Dr Sheetal Ballal, Organising Secretary, Bangalore West Lions Superspeciality Eye Hospital, No 5, Lions Eye Hospital Road, Off J C Road, Bangalore 560002