ONLINE ACCREDITATION FORM (Single and with spouse category):

EARLY BIRD NOW CLOSED. REGULAR ACCREDITATIONS CONTINUE.

On popular request, we are also offering daily rates for groups and on-site walk-in visitors.

For details, contact : neelima.mathur[at]gmail.com / +91805720 3333.

General :

For group accreditations, please contact neelima.mathur[at]gmail.com

FIRST NAME :

MIDDLE NAME :

LAST NAME :

MOBILE 1 :

SPOUSE :

FIRST NAME :

MIDDLE NAME :

LAST NAME :

MOBILE 1 :

MOBILE 2 :

CONTACT ADDRESS :

CONTACT ADDRESS

EMERGENCY CONTACT NO :

PROFESSION + DESIGNATION :

NAME OF ORGANISATION / INSTITUTION IF ANY :

The above is mandatory for Press and single student accreditation

NAME OF FACULTY MEMBER (In case of students):

MOBILE NO. OF FACULTY MEMBER:

The above is mandatory for single student accreditation

Please upload your photograph in jpeg format and file size less than 1MB.

For with spouse accreditations, please upload one photograph each of less than 1 MB.

CATEGORY OF ACCREDITATION : Please tick your option below.

Early Bird rates applicable till February 15, 2013

General :

a) Single accreditation: Rs. 5,000 [Early Bird: Rs. 4,500]

b) Single accreditation with spouse: Rs. 8,000 [Early Bird: Rs. 7,000]

d) Single accreditation for university media course / film school students: Rs. 2,500 [Early Bird: Rs. 2,000]

Press: Rs. 4,000 [Early Bird: Rs. 3,500]

For Uttarakhand residents / institutions / organisations:

a) Single accreditation: Rs. 3,500 [Early Bird: Rs. 3,000]

b) Single accreditation with spouse: Rs. 5,000 [Early Bird: Rs. 4,000]

d) Single accreditation for university / film school students: Rs. 1,750 [Early Bird: Rs. 1,250]

PAYMENT MODE :

( Please tick your option )

CHEQUE

FOR CHEQUES :

Cheque in the name of 'FOUNDATION FOR RESPONSIBLE MEDIA'

At the back of cheque, please write the following account details:

FOUNDATION FOR RESPONSIBLE MEDIA

ACCOUNT NO : 000310 0023 7779

Please provide details below and deposit in the nearest HDFC bank in your city.

Cheque no:

Date :

Amount :

FOR BANK TRANSFERS :

Routing via :

Foundation for Responsible Media

Account Number :

000310 0023 7779

RTGS / NEFT IFSC Code : 

HDFC0000003

Bank Address :

G-3/4 Surya Kiran Building,19, K.G. Marg, New Delhi 110 001

Kindly intimate transaction details to neelima.mathur[at]gmail.com

PLEASE RE-CHECK YOUR FORM AND ENSURE ALL DETAILS ARE CORRECTLY FILLED IN.

YOU WILL RECEIVE AN EMAIL INTIMATION OF THIS FILLED FORM.

IF YOU STILL WISH YOU CAN PRINT NOW BEFORE PRESSING SUBMIT.