NIA FAIR SEMINAR-2014_ LIABILITY INSURANCE

NIA – FAIR SEMINAR ON LIABILITY INSURANCE 16.12.2014 – 18.12.2014 REG GISTRATIO ON N FO ORM M R RE EGI IS ST TR RA AT TI ION F FOR RM PERSONAL PARTICULARS Name : Mr. / Mrs. / Ms. / Dr. / Prof.: __________________________________________________________ First Name Middle Name Surname Position held :__________________________________________________________ Name and address of the __________________________________________________________ sponsoring company : __________________________________________________________ __________________________________________________________ Contact Details (with country code) : Tel.No____________________ Mobile No.______________________ E-mail :__________________________________________________________ Nationality :__________________________________________________________ Passport No. and valid up to : __________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------------------------------------- REGISTRATION DETAILS Accomodation (Please tick) : Residential / Non-Residential Indian Overseas Participationfees :Residential: INR 28,000.00 US$ 464.00 Non-Residential: INR 16,800.00 ------------ Service Tax @ 12.36% will be charged extra. Last date of Registration : Registration forms along with fees should reach us on or before 10 December, 2014. th ------------------------------------------------------------------------------------------------------------------------------------------------------------------- Signature of the Nominee Signature & Seal of the Nominating Authority -------------------------------------------------------------------------------------------------------------------------------------------------------------------- Mail this form to : National Insurance Academy, Balewadi, Baner Road, NIA PO, Pune 411045, India E-mail: [email protected]; [email protected] PAYMENT DETAILS EITHER 1. By Demand Draft drawn in favour of `National Insurance Academy’ payable at Pune. OR 2. By Bank transfer as per details given below Bank Details for Indian Participants Bank Details for Overseas Participants Account Holder – National Insurance Academy Account Holder – National Insurance Academy Name of the Bank - Bank of Maharashtra, Name of the Bank - Bank of Maharashtra Address of the Bank - Balewadi Branch Address of the Bank - Pune Overseas Branch Balewadi, Baner Road, NIA PO Sadashiv Vilas, 1183/ A, F.C. Road Pune - 411045 Shivajinagar, Pune - 411 005 (India) Branch Code No. - 1121 Branch Code No. - 1144 Account Number - 20008885848 Account Number - 20008885848 Type of bank account - Savings Type of bank account - Savings MICR Code of the bank - 411014074 Swift Code : MAHBINBBOCP IFSC Code - MAHB 0001121 Mode of Electronic transfer available :- ECS/RTGS/NEFT (Kindly note that the bank charges are to be borne by you and the full fee amount is paid to us)