EMPOWERING THE CHILD WITH AUTISM 1-3 February 2017; 9:00 am 5:00 pm – The National Centre For Autism REGISTRATION FORM This is a fillable form. on the grey boxes to enter information. Press to move between items. Alternately, print and fill the form with a ‘tab’ pen. Please use LETTERS. Attach a copy of your demand draft / online transaction receipt. Keep a photocopy for your records. AFA Membership No: Parent Professional (If Applicable) PERSONAL INFORMATION Prof Dr Mr Ms First Name: Last Name: Residential Address: Country: Pin Code: State: Contact No: Email: Designation: Organisation Name: Organisation Address: State: Country: Pin Code: Email: Website: Contact No: REGISTRATION DETAILS As Applicable) Students Professionals Parents INR 2,000 AFA members INR 3,500/- AFA members INR 3,000/-Per Parent Non members INR 4,500/- Non members INR 4,000/-Per Parent 5 or More Professionals (from the same 10% Discount (if applicable) Parent Couple organisation) Total Amount: Payable Through: Online Bank Transfer Demand Draft (in favour of for Autism’ payable at New Delhi) ‘Action Online Transaction / Demand Draft No: Dated: Drawn On Bank: Full Name: PAN No: (Must be of the same Receipt in favour of: individual/organisation )
EMPOWERING THE CHILD WITH AUTISM 1-3 February 2017; 9:00 am – 5:00 pm The National Centre For Autism REGISTRATION FORM This is a fillable form. on the grey boxes to enter information. Press ‘tab’ to move between items. Alternately, print and fill the form with a pen. Please use LETTERS. Attach a copy of your demand draft / online transaction receipt. Keep a photocopy for your records. Parent Professional AFA Membership No: (If Applicable) PERSONAL INFORMATION Prof Dr Mr Ms First Name: Last Name: Residential Address: State: Email: Country: Pin Code: Contact No: Designation: Organisation Name: Organisation Address: State: Email: Country: Website: Pin Code: Contact No: REGISTRATION DETAILS As Applicable) Students INR 2,000 Professionals AFA members INR 3,500/- Non members INR 4,500/- Parents AFA members INR 3,000/-Per Parent Non members INR 4,000/-Per Parent 10% Discount (if applicable) Parent Couple 5 or More Professionals (from the same organisation) Total Amount: Payable Through: Online Bank Transfer Demand Draft (in favour of ‘Action for Autism’ payable at New Delhi) Online Transaction / Demand Draft No: Dated: Drawn On Bank: Receipt in favour of: Full Name: PAN No: (Must be of the same individual/organisation )