PARTICIPANT


Name : Title : Prof.  Dr.  Mr.  Ms.
Institution :
Telephone : Fax :
Date of Birth : Sex : Male  Female
Email : Mailing Address :
ACCOMPANYING PERSON(S)
Name : Title : Prof.  Dr.  Mr.  Ms.
Age : Sex : Male  Female
Name : Title : Prof.  Dr.  Mr.  Ms.
Age : Sex : Male  Female
PAYMENT INFO
Member Type Amount Paid for
A.   *Member BDT 800 Member
B.   Non-member BDT 1200 Non Member
C.   *Student BDT 700 Student
*Proof Required
Password : (minimum 6 characters)

        
PAYMENT METHOD
Payment should be made by bank draft or cheque payable to the Bangladesh Society of Medical Biochemists.


Please return the form on or before 20 December 2014 with payment to Conference Secretariat, Medical Biochemistry Conference 2014. Department of Biochemistry, Bangabandhu Sheikh Mujib Medical University, Dhaka-1000, Bangladesh. Phone:+880-01711288426, +880-01711600469. email:bsmb14@gmail.com, website:www.bsmb.net.bd