Registration Form
Type of Registration: ( Please tick the appropriate one )
Reception Type Member      Delegate      Delegate Cum Accomodation      Post Graduate    Accompanying Person   
Member(ISA,SAARC,Other Countries):________________    Membership No:_____________________
Personal Details
*Name:
*Name To be printed on a badge:
*Designation:
*Institution:
Date of birth: Nationality Sex: Male   Female  
Correspondance Address City:
State: Country Pincode::
Ph(Off): Residential Mob::
Email:
Passport and visa (for other countries)
Passport NO:    
Other Details
No. of persons Accompanying: Adult: Children: Food: Vegg: Non-Veg
Name of the acompanying Person 1:MR/MRS   Age:
Name of the acompanying Person 2:MR/MRS   Age:
Presenting Paper: YesNo:
Workshop Details
Workshop Regular Preferences
1. Neuro Monitoring
2. Neuro Monitoring
3. Neuro Monitoring
Copyright 2011 © Bangladesh Society of Anaesthesiologists (BSA)
All Rights Reserved