VC Circle S: GROWTH CAPITAL FORUM s1

News Corp VCCircle Loyalty Summit 2017 December 13, Four Seasons Hotel, Mumbai REGISTRATION FORM

Date of Registration: - ---/---/--- Registration:-

Standard Fees:- INR 8000 + 18% GST per attendee

DELEGATE DETAILS:

Company Name Address

Contact No: Fax No: Category (please tick Company/ I-Banker/ Consultant/ Investor one) Entrepreneur Adviser Delegate Name Designation Email Id HandPhone Number

* Would you like to receive the Daily VCCircle Newsletter with all updates of the day? Yes/No

PAYMENT DETAILS: Kindly send DD/Cheque in favor of “Mosaic Media Ventures Pvt Ltd”, payable At Par. Bank Name Branch Name Cheque/DD No. Amount

You can also directly deposit cash, submit cheque or transfer online to our HSBC Bank a/c: Account name: Mosaic Media Ventures Pvt. Ltd. Account no: 499324051001 Branch Name: Noida Sector 18 IFSC Code: HSBC0110007 PAN: AAECM9813A Service Tax Code - AAECM9813AST001

______Name and Signature Cheque/DD has to be sent to: Mosaic Media Ventures Pvt Ltd A-83, Ground Floor, Sector-2, Noida-201301. Phone: 0120-4171111 | Fax no: 0120-4171124 Contact Person: Sandeep/Krishna Email: [email protected]

Cancellation Policy: There is no cash refund in case you cancel the registration from your end. We will issue a credit note for an equivalent amount which you can adjust/utilise against any of our future events (under the validity period) if the registration is cancelled at least 3 working days before the event, post which NO credit note will be issued. Please talk to Sandeep/ Krishna for further details.

For more details visit us at: www.vccircle.com