Please download the attached word document and send it after completion to coordinator of the Optometry Congress – 2020

academy@visioncaresl.com

ms-word_1475356c

VCA_Optometry Congress Registration Application Form_2020

 

CONGRESS REGISTRATION FORM Optometry Day And 11th Vision Care Annual Scientific Sessions, June 14, 2020 at Oakroom, Cinnamon Grand, Colombo 03.
PART A: PERSONAL DETAILS (Please complete this from BLOCK LETTERS)
Title:  □ Prof.    □ Dr.     □ Mr.    □ Ms. Gender:  □ M     □ F
Given Name: Surname:
Organization:
Address:
City: State / Province:
Country: Post Code:
Tele: (     ) Fax:  (     )
Email:
Dietary Requirement: □ Vegetarian Submission of Abstract / Poster: □ Yes      □ No

 

PART B: REGISTRATION ORDER DETAILS
REGISTRATION TYPE UNIT PRICE
Early Bird Registration (Postmarked 28.02.2016) □  US$ 100 / LKR 3,000
Registration till 31.06.2016 □  US$ 125 / LKR 3,500
Onsite Registration □  US$ 150 / LKR 4,000
The registration  fee includes participation in the lectures, scientific paper, industry sessions, poster sessions, coffee breaks and lunch.

 

PART C: PAYMENT METHODS
       I have   enclosed a US$ bank draft / LKR cheque payable to “Vision Care Optical Services (Private) Limited” in the amount of …………………… USD / LKR as the registration fee.Name of Bank:  ………………………………………………………………………………Draft /Cheque No.:  ………………………………………………………………………………
       Bank Transfer: (Please forward a scanned copy of fund remittance notice issued by the bank to the email address of secretariat: academy@visioncaresl.com Name of the Bank:         Sampath Bank PLC Branch:                            Headquarters Beneficiary Name:         Vision Care Optical Services (Private) LimitedAccount Number:          002930014314Swift Code:                      BSAMLKLXXXX

Please return the completed registration form with appropriate registration fee to the following addresses;

Ms. Shehani Randeniya

Coordinator,

Vision Care Academy,

Level 4, No 505,

Union Place

Colombo – 02.

SRI LANKA.

Tel:   +94 771 067 746

Email:  academy@visioncaresl.com

DATE: …………………………………………                                    SIGNATURE: ……………………………………………