APPLICATION FORM FOR MEMBERSHIP TO ABOUT SIKKIM … · Budget rooms 1500 (preference to pg.'s)...
Transcript of APPLICATION FORM FOR MEMBERSHIP TO ABOUT SIKKIM … · Budget rooms 1500 (preference to pg.'s)...
THEME: HUGS NOT DRUGS
The impact of drug abuse & dependence can be far-reaching, from damaging the person as well as society physically, financially, emotionally as well as socially. Drug abuse has been a menace worldwide & its trending with the youth of prime age results in loss of potential workforce of the society.
Venue : Auditorium, Level VI, Sikkim Manipal Institute of Medical Sciences,
th5 Mile, Tadong, Gangtok, Sikkim
th thDate : 6 and 7 April 2018.
ABOUT SIKKIMSikkim Location: Latitude: 27-28°North, Longitude : 88-89°East
Sikkim is a beautiful Himalayan state located in north-eastern part of India sharing borders with China, Nepal and Bhutan. Its scenic beauty is famous worldwide.
Places of interest:(1) Guru-Dongmar Lake .(2) Yumthang valley with hot springs.(3) Seven sister falls.(4) Singhik closest view of
Mt. Kanchendzonga).(5) Samdruptse, Solophok Chardham,
Sai Mandir, Krishna Mandir(6) Temi tea garden, Tarey Bhir(7) Buddha Park, Ravangla.(8) Tsomgo (Changu) Lake, Baba Mandir,
Nathula pass.(9) Gangtok Ropeway and famous MG Marg.
Adventure sports :
(a) Trekking: Himalaya trek, Monastic trek,Rhododendron trek, Kanchendzonga trek.
(b) River rafting: Teesta experience & RangeetExperience.
(c) Yak ride: Dzongri & Tsomgo lake.
(d) Paragliding: Gangtok
(e) Bird watching: Ravangla
APPLICATION FORM FOR MEMBERSHIP TOTHE INDIAN SOCIETY OF TOXICOLOGY
ToDr. V.V. PillayTreasurerIndian Society of ToxicologyPoison Control Center Amrita Institute of Medical SciencesCochin 682041 Kerala
Dear Sir,
I wish to become a Life Member/Annual Member of the Indian Society of
Toxicology. I am furnishing the required particulars below, and request you
to kindly enroll me in the Society. The fee (Rs.3000/Rs.300 for Life
Membership/ Annual Membership is enclosed as a Demand Draft
(No.….................................…… of …....................………. Bank), in the name of
“President, Indian Society of Toxicology” payable at Ernakulam. I am also
enclosing a copy of my Curriculum Vitae and 2 Passport size B/W
photographs.
Yours sincerely,
(Signature)
Full Name (in Block Letters): __________________________________________
Father's / Husband's Name: __________________________________________
Date of Birth: _______________________________________________________
Qualifications (with name of University, date of passing):
___________________________________________________________________
Official Address (with Designation, Ph. No& E-Mail ID)
Permanent Address: ________________________________________________
___________________________________________________________________
*Rs. 2500/ Rs.250 for Life/Annual Membership in the case of PG Students.All payments must be in Indian currency only.
TRANSPORT & COMMUNICATION:
(a) Nearest airport is Bagdogra in North Bengal which is 124Kms &
approximately 4hrs drive from Gangtok.
(b) The closest railway station is New Jalpaiguri (NJP) in North Bengal
which is 125Kms and approximately 4hrs drive from Gangtok.
(c) Gangtok is connected by all weather road to Siliguri which is
approximately 115 kms . The Sikkim Nationalised Transport provides
regular bus service to Siliguri, plenty of private buses & Taxis are also
available. Booking facilities are available in Siliguri & Gangtok.
(d) Sikkim Tourism operates daily a five-seater helicopter service between
Gangtok & Bagdogra.
TOXOCON-12REGISTRATION FORM
th th6 - 7 APRIL, 2018SMIMS, GANGTOK, SIKKIM
Delegates are requested to fill the Registration form (One form is applicable to one delegate and co delegate only). Kindly send the filled-in registration form along with payment proof/ demand draft.
Please feel free to distribute copies of this brochure to other interested colleagues also.
Please complete the form below in CAPITALS, strike out whatever is not applicable.
Delegate /Post graduate student
Accompanying Co-delegate: Yes/No
Name: Dr./Mr./Mrs./Ms.___________________________________________________
Department: _______________________________________________________________
Organization Address: ______________________________________________________
__________________________________________________________________________
(Mobile). __________________________ Email: _________________________________
Title of Presentation :Type of presentation : Paper/posterLife member of IST : YES / NOAccommodation : Required/Not requiredCategory of room : Suites premium/Super Deluxe/ Deluxe/ Deluxe triple
bedded/ Budget roomChoice of room : Independent room/sharing basis (no. of persons and name
of accompanying person)Payment Details-
DETAILS AMOUNT
Registration Fees:
Co delegate fees:
Accommodation Advance:
Total (In Words)
Please clarify your method of payment: Demand Draft / NEFT (Cheques are not accepted)
Payments to be made by Demand draft in favor of “TOXOCON-12” payable at Gangtok.
Demand Draft No: ____________________________________ Date: ____/____/_____
Amount: ______________________________Bank & Branch Name: ________________
Please mention the name on back of the Demand Draft.
The details of bank transfer:
Name ______________________________ Bank & Branch Name ___________________
NEFT No.___________________________ Date ___________________
**Registration shall not be processed until payment is received.
PG students should attach a certificate from HOD.
MESSAGE FROM THE ORGANIZING CHAIRMAN
ORGANIZING COMMITTEE:
Dear friends
thWe feel privileged to host 12 Annual National Conference of Indian Society of Toxicology, TOXOCON-12 at Dept. of Forensic Medicine & Toxicology, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim.
The conference is scheduled to be held on 6th-7th April, 2018 in beautiful city of Gangtok. The theme for TOXOCON-12 “Hugs not Drugs”, is aptly chosen looking at high rate of substance abuse prevalent all over. This conference is aimed to attract specialists from forensic medicine, medicine, pharmacology and psychiatry.
Sikkim boosts of beautiful landscapes, snow -capped mountains, lakes, temples, monasteries, rivers and much more. April is peak tourist season in Gangtok with pleasant weather.
Looking forward to welcome you all in April 2018 at Sikkim
On Behalf of Organizing team.
Regards
Dr. Prateek RastogiProfessor & Head, Dept. of Forensic Medicine & ToxicologySikkim Manipal Institute of Medical Sciences, Gangtok
Chief Patrons: Lt. Gen. (Dr) M D Venkatesh, VSM (Retd) Hon'ble Vice Chancellor, SMU
Prof (Dr) Ashis Sharma Registrar, SMU
Patron: Air Marshal (Dr) G S Joneja, VM (Retd) Dean, SMIMS
Organizing Chairman : Dr. Prateek Rastogi
Organizing Vice Chairman : Dr. K B Gurung
Organizing Secretary : Dr. Ashim Mishra
Joint Organizing Secretary : Dr. O T Lepcha
Treasurer : Dr. Karma M D Bhutia
Joint Secretary : Dr. Chedup Lepcha
ABSTRACT GUIDELINES (paper and poster)
The Abstracts must be structured, typed in English using MS-Word format
with double spacing and Times New Roman (font size 12). Title should be in
uppercase (font size 14). Abstract should not exceed 300 words and must be
followed by 3-5 key words. The name of authors and affiliations should follow
immediately under the title, highlighting the name of presenting author. DO
NOT include degrees or professional designations. Original research, review
papers, case study, case series etc. are welcome for presentation.
Only one paper/poster per delegate is permitted. Final decision regarding the
type of presentation (Paper/Poster) rests with the organising committee.
Details for paper/poster presentation will be informed to participants along
with acceptance letter.
stLast Date of Abstract Submission : 31 January 2018.thIntimation of acceptance : 15 February 2018.
Must be submitted by e-mail only :
Contact Details:Email: [email protected]
Dr. Prateek Rastogi : +91 9448501376 Organizing Chairman
Dr. Ashim Mishra : +91 8001171225 Scientific Committee Chairman
Dr. Karma M D Bhutia : +91 9734870986 Registration Committee
Chairman
Dr. Chedup Lepcha : +91 9474981193 Accommodation Committee
Chairman
Conference attendance and paper/poster presentation is open to all but entry
to award session is restricted to life/annual members of the Indian Society of
Toxicology. Non-members can avail the opportunity to compete in the award
session by enrolling as either annual or life members of IST. Best paper/poster
in Faculty and PG category will be awarded separately. The newly enrolled
members can also reap the benefits of getting their papers published in the
prestigious Journal of Indian Society of Toxicology (JIST) as per the rules and
regulations of the society.
NOTE: There will be a TOXIQUIZ for the PG students on substance abuse
during the conference and winners will be awarded by IST. (Open only to
members of IST)
(as e mail attachment only)
REGISTRATION FEE IN INDIAN RUPEES
Registration TOXOCON - 12
Dates Delegates Co-delegates Postgraduate students
Up to th30 Nov 2017 4000 3000 3000
Up to st31 Jan 2018 4500 3500 3500
Up toth15 Mar 2018 5000 4000 4000
Spot registration 5500 4500 4500
*The Registration fees is inclusive of conference registration fees, the conference kit, lunch for two days, banquet dinner on1st day, breakfast and tea for two days.
*Co delegates are not entitled for conference kit.
The transport facility to and fro from the hotel to the venue will be provided once in the morning and once after the end of the day's session if accommodation is booked through organizing committee.
Room category Double occupancy*
Suites premium 7000
Super deluxe 5000
Deluxe 4500
Deluxe triple bedded 3500
Budget rooms 1500 (preference to pg.'s)
*Taxes extra.The hotel booking can be done by the accommodation committee if informed latest by 31st January 2018 as April is a peak tourist season in Sikkim. Advance for accommodation booking will be levied as one-day charge depending upon the type of room preferred. Registration fee and accommodation advance is refundable with 50% deduction if cancellation is done before 31st January 2018 after which no refund will be entertained. Accommodation booking by the organizers after 31st January 2018 shall subject to availability of the hotel rooms. All refunds requests will be processed after the conference.
Bank Details:Account Name : TOXOCON 12Bank Name : Canara BankBank Account No. : 8676101009218
Branch : Tadong BranchIFSC code : CNRB0008676 Branch MICR code : 737015002