Registration Form. Name of Attendee Designation Institution/Hospital Telephone No id Address. Before 31 st October 2018

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1 Annual Conference of Haryana Association of Gynae Endoscopy Learning from Basic to Advanced Gyne Endoscopy Live Workshop on 8th December at Hospital QRG, Faridabad Conference on 9th December at Hotel Radisson Blu, Faridabad Registration Form Name of Attendee Designation Institution/Hospital Telephone No id Address Fee Deadline NON-HAGE Members Before 31 st October 2018 After 31 st October 2018 On spot registration INR 4000 INR 5000 INR 6000 HAGE Members INR 2500 INR 3000 INR 4000 PG Students INR 2000 INR 2500 INR 3000 Charges for the accompanying person will be INR 2000 for each meal (Lunch/Dinner). Total Amount (in words) DD/ Cheque No Bank Cheque in favour of payable at Faridabad. Date Signature Registration Fee includes Course Registration, Meals and Gala Dinner at the conference.

2 ACCOMODATION BOOKING FORM Conference Reg. No. Full Name Address for Communication Telephone with STD code Mobile No. Residential Packages S. No. Hotel Name Single Occupancy Double Occupancy 1. Radisson Blu (Conference Rs. 5900/- Rs. 7080/- Venue) 2. Park Plaza Rs. 4000/- Rs. 4500/- 3. Grand Delite Rs. 3000/- Rs. 3200/- 4. Ginger Hotel Rs /- Rs /- v Residential package is inclusive of all taxes. v Breakfast at conference venue. v Subject to availability. I am herewith enclosing a Demand Draft/Cheaque/NEFT No. dated drawn on bank for Rs. as accommodation charges. Date: Signature: Send your accommodation form along with your registration form and payment details to Secretariat QRG Health city Hospital, Faridabad Mobile no.: , hagecon2018@gmail.com

3 FARIDABAD Conference Theme: Gynecological Endoscopy Radisson Blu Hotel, Faridabad ABSTRACT FORM Please go through the guidelines mentioned below before filling this form. Author Prof./Dr./Mr./Ms. Co-Authors (Please mention presenting author) Institution Address City Pin code State Tel. Fax Mobile no. Mode of Presentation (Please choose one from below) 1.Power Point Presentation 2.Poster 3.Video Title of Paper:

4 FARIDABAD Conference Theme: Gynecological Endoscopy Radisson Blu Hotel, Faridabad ABSTRACT GUIDELINES Theme: Minimally Invasive Gyne Surgery/Misc. 1) Abstract must be submitted in English, Font size 12pt, Times New Roman. 2) Registration is must. 3) Abstract title to be limited to 20 words in BOLD UPPER CASE. 4) The abstract text to be limited to 250 words and is to be structured with the following headings: (in bold) - Introduction - Material and Methods - Results - Conclusions 5) Please do not include tables, graphs and images in the abstract. 6) Presenting authors of abstract must be registered participants. 7) Abstracts must be original and must not be or have been published or presented at any other meeting. 8) Abstracts must be received by the announced deadline. Abstract received after the deadline will not be considered. 9) The presenting author is required to ensure that all co-authors are aware of the content of the abstract before submission. 10) Abstracts stating data will be discussed in the presentation will not be accepted. ABSTRACT DEADLINE: 31 st October 2018 Send the filled Abstract Form with Abstract to Hagecon2018@gmail.com Conference Coordinator Priya Babbar ( )

5 Registration Form Haryana Association Of Gynae Endoscopy (HAGE) Name: Age: Designation: Institution: Address: City: State: Pin Code: Country: Mobile No.: Id: Registration Fee Fee for life membership of HAGE INR 6500/- Please send the filled registration form along with demand draft in favor of HARYANA ASSOCIATION FOR GYNAECOLOGY ENDOSCOPY President Dr. Ragini Agrawal ( ) Vice-Presidents Dr. Nisha Kapoor ( ) Dr. Neeru Thakral Dr. BB Dash HAGE Secretariat W Pratiksha Hospital, Sec 56, Near Club Florence, Gurgaon id: hage2017haryana@gmail.com