Name : LUGI Membership No: Address : Mobile No : Email :
I would like to confirm my participation in the 15th Annual Convention of LUGI to be held at Hyderabad between 05th & 07th October, 2017.
I understand that the total costs of Convention are as per details given in the Circular Communication No.: 001 / 2017- 2018 dated 11.05.2017.
Plan opted : Plan APlan BPlan C
Accommodation : YesNo
As per my opted plan my total registration fee is as follows: Rs. _________
Code No.: Agency (or) CLIA Dev Officer (or) SBA …………………………………
Insurer:
Name of the Branch : …
Name of the Division / Region:
Mode of Payment : CashDirect DepositChequeDDRTGS/ NEFTCredit Card
I have attached the following:
Photocopy of cash Direct DepositChallanCheque / DDUTR Number / Bank Transfer detailCopy of Credit / Debit swiping slip