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REGISTRATION FORM

	1.	Title:
	2.	Name:
	3.	Designation:
	4.	Affiliation/Organization/ Institution:
	5.	Mailing Address:
	6.	City:
	7.	Pin Code:
	8.	Country:
	9.	Phone:
		Country Code Area Code Phone No.
	10.	Fax No.
		Country Code Area Code Phone No.
	11.	E-mail:
	12.	Accompanying Persons 1:
	13.	Accompanying Persons 2:

Registration Fee

Guideline		Delegates	Residents (Certificate to be Attached)
Early Bird	31 Aug	Rs 1000/-	Rs 500/-
Routine	31 Oct	Rs 1500/-	Rs 750/-
Spot	at venue	Rs 2000/-	Rs 1000/-

The Fee should be paid by Demand Draft Drawn in favor of "INDO-US Stroke Symposium 2005" and should be send to the conference secretariat.

Conference Secretariat
Room no. 708, Neurosciences Centre
All India Institute of Medical Sciences
Ansari Nagar, New Delhi-110029, India
Phone. 0091-11-26588700 Ext. 4794, 26594794 Fax. 0091-11-26594794
E-mail: indousa2005@yahoo.com Website: www.indousstroke.com