RESCON 2016 - Registration Form

1. Surname/Last Name:

2. Name with Initials: (Rev. / Prof. / Dr. / Mr. / Ms.) - Place ‘√’ in the appropriate box

3. Affiliated Organization / Institution:

4. Mailing Address:

5. Country:

6. Contact Telephone No:

7. Email:

8. NIC No (Sri Lanka) / Passport No:

9. PGIS Student : No Yes If yes, provide Student ID No:

10. Nature of Participation: Presenter Participant only

11. I wish to attend the Congress Dinner on 8th Sep 2017: Yes No

12. Meal Preference: Chicken Fish Egg Veg.

Payment of Registration Fees (includes Proceedings, Congress Dinner, Lunch and Refreshments): Local Category International Students Academic staff/others Early Bird* Registration Fee LKR 750/- LKR 1250/- USD 75 Regular** Registration Fee LKR 1250/- LKR 2000/- USD 100 Late/onsite registration Not Allowed Not Allowed Not Allowed * Until August 8, 2017 ** August 9 - 30, 2017 International Applicants Registration Fee to be deposited to the A/C No. 2233593 (SWIFT CODE: BCEYLKLX) at Bank of Ceylon, Peradeniya, Sri Lanka. Please attach a scanned copy of the Bank Slip with the applicant’s name. Date of Deposit/Wire Transfer: Local Applicants Mode of Payment: Deposit to the PGIS A/C No. 0081041788 at Bank of Ceylon, Peradeniya. Please attach a scanned copy of the Bank Slip with the applicant’s name. Date of Deposit: By cheque made in favour of ‘Postgraduate Institute of Science’. By cash: Accepted only at the shroff counter of the PGIS.

Applicant’s Signature Date

Thank you for completing the registration form. The competed registration form along with payment slip/scanned copy should be either e-mailed to [email protected] or posted to Assistant Registrar, Congress Office, Postgraduate Institute of Science, PO Box 25, University of Peradeniya, Peradeniya, Sri Lanka.