Registration Form

31st National Conference of Indian Association

for Social Psychiatry

“Generational Transformation in 21st Century: Focus on Sexuality, Gender and Relationships”

4th - 6th November 2024

First Name *

Last Name

Date of Birth

GenderMaleFemaleOthers

Address *

District

State *

ZIP / Postal Code

Country

Mobile *

Email Address *

Qualification

Year

MCI / Medical Registration Name *

MCI / Medical Registration Number *

Do you have an accompanying person? *YesNo

Accom.Person Name

Relationship

Do you need any accommodation to be set up? *YesNo

Transaction ID/ Payment ID /UTR No

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PAYMENT SHALL BE RECIEVED BY

BANK NAME : STATE BANK OF INDIA

ACCOUNT NAME : KARNATAKA SEXUAL SCIENCES ACADEMY (R)

ACCOUNT NUMBER : 38450832183

GST NUMBER : 29AADTK9027A1ZP

IFSC CODE : SBIN0040249

ADDRESS : STATE BANK OF INDIA,

JSS COLLEGE BRANCH, RAMANUJA ROAD,

MYSORE - 570004, KARNATAKA