Fellowship Course in Advanced Laparoscopic Surgery : FALS HERNIA

Indian Association of Gastrointestinal Endo-Surgeons 13, 14 & 15th January - 2017

Organised by :

Dr A.K. Kriplani, Director & HOD

& Dept. of Minimal Access, Bariatric & GI Surgery, FMRI, Gurgaon

Tel: +91 9599425744 E-mail : falshernia2017@gmail.com

---- Venue ----

'Meditorium’ - 1st floor

Fortis Memorial Research Institute

Opposite HUDA City Center, Sector 44, Gurgaon, 122002

Dr. Ramesh Agarwalla

President – IAGES

Dr. A.K. Kriplani

Organizing Chairman

The Fellowship certification course started by IAGES was an effort to advance endosurgery throughout the country. The 1st Basic Fellowship course was organized by Dr A.K. Kriplani in New Delhi in April 2007 along with launching of IAGES Text Book of minimal access surgery. It is our privilege to invite you to the 1st ADVANCED FELLOWSHIP COURSE IN LAP HERNIA REPAIR: “FALS HERNIA” with the same fanfare and the legacy of the FIAGES courses linked to Dr. A.K. Kriplani. Laparoscopic hernia surgery is increasingly becoming popular and awareness of the patients towards the benefits has been tremendous in recent years. The concepts in laparoscopic hernia management are seeing a dramatic change with increasing emphasis on restoration of functional anatomy of the abdominal wall and cosmetic appearance besides decreasing recurrences and pain. There are varied guidelines and suggestions including many controversies regarding the hernia repair and the management of the defect. There has been an air about the effects of pneumoperitoneum on the defect and tackling it. All these emphasize on the need of an advanced course that shall simplify the controversies and teach the Lap hernia surgery threadbare to the upcoming advanced laparoscopic surgeons. The Venue of the Course is Fortis Memorial Research Institute, Gurgaon, an institution with infrastructure and ambience matching the best in the world (ranked no. 2 in the world & the only Indian hospital in the ranking). We bring you the opportunity of the advanced fellowship course in laparoscopic hernia repair by Dr A.K. Kriplani and join the big league of niche group of advanced lap hernia surgeons.

We welcome you to the millennium city Gurgaon for an experience of a lifetime of fellowship, knowledge sharing, friendship and warm hospitality.

WELCOME MESSAGE

Dr. Sayandev Dasgupta

Hon. Secretary

Dr. H.P. Garg

FALS Convener

ORGANIZING COMMITTEE

Organizing Chairman Dr. AK Kriplani

Organizing Secretary Dr. Rashmi Pyasi

Co-organizing Secretary Dr. Shashank Rastogi, Dr. Prateek Agarwal

Chief Patron

Dr. Malvinder Mohan Singh

Patron

Dr. Bishnu Panigrahi

Advisors

Col. Harinder Chehal

Dr. Simmardeep Gill

Dr. Yash Pande

Mr. Vijay Sethi

Members

Dr. Lalmalsawma Ralte

Dr. Jitender Verma

Dr. Devyani Gautam

Dr. Amir Mohd Ansari

Ms. Nilanjana Roy

FACULTY

A.K. Kriplani, New Delhi

A K Sarda, New Delhi

Abhay N Dalvi, Mumbai

Achal Gupta, Gwalior

Amitabh Goel, Indore

Anil Sharma, New Delhi

Anurag Srivastava, New Delhi

Arun Prasad, New Delhi

Ashish Vashist, New Delhi

Ashwin Masurkar, Gokak

B. Krishna Rau, Chennai

B. Ramana, Kolkata

Chintamani, New Delhi

C K Durga, New Delhi

Deborshi Sharma, New Delhi

Deep Goel, New Delhi

Deepraj Bhandarkar, Mumbai

H.G. Doctor, Mumbai

H.P. Garg, New Delhi

Jaya Maheshwari, Jaipur

John Thanakumar, Coimbatore

JB Agarwal, Mumbai

K.N.Shrivastava, New Delhi

K Ravindranath, Hyderabad

Kuldeep Singh, Ludhiana

Lakshmi K Kona, Hyderabad

L P Thangavelu, Coimbatore

M.G. Bhat, Bengaluru

Manish Baijal, New Delhi

M C Misra, New Delhi

Meenakshi Sharma, Gurgaon

Parveen Bhatia, New Delhi

Pawninder Lal, New Delhi

Pradeep Chowbey, New Delhi

Pradeep Jain, New Delhi

Rashmi Pyasi, Gurgaon

Rajesh Khullar, New Delhi

Rajinder Parshad, New Delhi

Rajiv Sinha, Jhansi

Ramen Goel, Mumbai

Ramesh Agarwalla, Kolkata

Randeep Wadhawan, New Delhi

R.K. Chirangoo, Jammu

Sandeep Aggarwal, New Delhi

Sandeep Dave, Raipur

Sarfaraz Jalil Baig, Kolkata

S D . Maurya, Agra

S P De Sarkar, Kolkata

Sayandev Dasgupta, Kolkata

Subhash Aggarwal, New Delhi

Subhash Khanna, Guwahati

Sumeet Shah, New Delhi

Sumit Shukla, Indore

Sunil Chumber, New Delhi

Sunil Popat, Ahmedabad

Suresh Deshpande, Kolhapur

Suresh Vashisht, Gurgaon

Sandeep Mukherjee, New Delhi

Sarfaraz Ali Baig, Kolkata

T.E. Udwadia, Mumbai

Tarun Mittal, New Delhi

Vandana Soni, New Delhi

V Venkatesh, Coimbatore

Vijay Borgaonkar, Aurangabad

V.K. Bansal, New Delhi

V Seenu, New Delhi

Vinay Sabharwal, New Delhi

Yogesh Agarwala, New Delhi

Zameer Pasha, Trichy

International Faculty: Dinesh Vyas, USA

IAGES EXECUTIVE COM M ITTEE

President

Dr. Ramesh Agarwalla

Honorary Secretary

Dr. Sayandev Dasgupta

North Zone Dr.Sumeet Shah South Zone Dr. Ashwin Masurkar

Central Zone Dr. Amitabh Goel West Zone Dr. Sunil Popat

East Zone Dr. Satyapriya De Sarkar

South Zone

Dr. T. Siva Kumar

Dr. L.P. Thangavelu

Dr. Easwaramoorthy

Dr. K. Govindraj

East Zone

Dr. Sreejoy Patnaik

Dr. C. R. Das

Dr. Vijay Mittal

Dr. Sarfaraz Jalil Baig

Immediate Past President

Dr. Abhay N Dalvi

President Elect

Dr. A. Zameer Pasha

Founder President

Dr. Tehemton Udwadia

Honorary Treasurer

Dr. Ramen Goel

North Zone

Dr. Subhash Aggarwal

Dr. Meenakshi Sharma

Dr. Manish Baijal

Dr. Vandana Soni

Central Zone

Dr. Siddharth Tamaskar

Dr. Achal Gupta

Dr. Sumit Shukla

Dr. Rakesh Shivhare

West Zone

Dr. Aparna Deshpande

Dr. Pramod Shinde

Dr. Roy Patankar

Dr. Jaya Maheswari

Executive Committee

Trustees

Dr. Kuldeep Singh Dr. AK Kriplani Dr. Suresh Deshpande

Dr. John Thanakumar Dr. V Venkatesh

Website In charge Dr. V. Venkatesh

FALS Board

Advisors

Dr. B. Krishna Rau Dr. H.G. Doctor Dr. Pradeep Chowbey

Dr. K Ravindranath Dr. M.G. Bhat

Chairman Dr. Kuldeep Singh Convener Dr. Subhash Khanna FIAGES Board

Vice Presidents

Co-opted Members Dr. Deepraj Bhandarkar, Dr. Rajesh Khullar, Dr. Lakshmi K Kona

Dr. Satish Midha, Dr. Navneetha krishnan, Dr. Suresh Vasistha

Convener Dr. HP Garg

Co-convener Dr. Vijay Mittal, Dr. Sunil Popat, Dr. Amitabh Goel,

Dr. Pramod Shinde, Dr. Sarfaraz Jalil Baig

DAY 1: 13th January 2017 LECTURES: 20min + 10min discussion 0900 to 1100

0900 – 0920hrs History of Laparoscopic Hernia Surgery

0930 – 0950hrs The most recent evidence everyone should know – lap inguinal hernia

1000 – 1020hrs Endoscopic anatomy of the inguinal region

1030 – 1050hrs Types of mesh, fixation devices, suturing & sealing

1100 – 1120hrs Opportunity to be clinical research leaders in surgery: laparoscopic

hernia is your forte

1130 – 1150hrs TAPP: elucidating the technique & keys to success

1200 – 1220hrs TEP: elucidating the technique & keys to success

1230 – 1300hrs DEBATE: Robot assisted inguinal hernia repair [10+10+5+5 +

10 discussion]

Lunch : 1310 to 1400hrs

1400 – 1420hrs Complications in lap inguinal hernia

1430 – 1530hrs Panel Discussion

• Mesh size, fixation or no fixation, tack or glue, mesh weight

• Choosing my right mesh

• Tricks that take me to a new level

• Emerging technology in inguinal hernia

• Additional risk factors & prevention

• SILS – present & future?

1530 – 1550hrs Recurrent inguinal hernia: management and pearls of wisdom.

1600 – 1700hrs Interesting Videos by Faculty

[5min edited videos each with 2min discussion]

Tea: 5pm and dispersal

MODULES

Session 1 : 0900 to 1100hrs

Session 2 : 1130 to 1310hrs

Session 3 : 1400 to 1700hrs

DAY 2: 14th January 2017

0900 – 0920hrs Introduction & surgical anatomy of lap ventral hernia

0930 – 0950hrs Mesh prosthesis, fixation devices & techniques

1000 – 1020hrs Lap repair of primary ventral hernia

1030 – 1050hrs Lap repair of incisional hernia

Tea break: 1100 - 1130hrs

1130 – 1150hrs Current literature & recommendations on defect closure in lap

ventral hernia

1200 – 1220hrs Debate on defect closure [8+8+2+2 + 10min discussion]

1230 – 1250hrs Robot assisted ventral hernia repair

Lunch: 1300 – 1345hrs

1345 – 1405hrs Lap hernia repair in difficult locations

1415 – 1435hrs Complications & their management in Lap ventral hernia repair

1445 – 1505hrs Redo surgery after previous lap ventral hernia repair

1515 – 1535hrs When do we choose open repair over laparoscopic: Component

Separation Technique

1545 – 1630hrs PANEL Discussion

• Techniques, tips & tricks for success

• Emerging technology in Lap hernia

• Tailoring hernia repair to patient needs

• Choice of mesh (is this the best?)

• Preoperative protocols

1630 - 1800hrs EXAMS [written for exam category / viva for non-exam]

DAY 3: 15th January 2017

0800 – 1400hrs Workshop

Viva for exam category candidates

MODULES

Session 1 : 0900 to 1100hrs

Session 2 : 1130 to 1300hrs

Session 3 : 1345 to 1800hrs

IAGES FELLOWSHIP COURSE DETAILS

IAGES will conduct a 3 days certification Fellowship course at Fortis hospital Gurgaon from 13th to

15th January 2017. The course will be a balanced mix of didactic lectures by eminent faculty with

ample time for discussion, video presentations, open house sessions, symposia and direct informal

interaction of groups with eminent faculty (Meet the Professor). We are planning to make available

Lap Mentor for live simulated hands-on surgical experience of advanced laparoscopy. The objectives of

the course are to impact/update theoretical knowledge by close interaction and improving hand eye

co-ordination. There will be many unique features in the course to make it more useful, convenient

and memorable for you.

At the end of the course the candidates will be assessed for the certification. The method of

assessment will be depend on whether the candidate is in examination category or non-examination

Category.

A live operative workshop will be held. Commonly practiced advanced laparoscopic hernia procedures

will be shown by eminent faculty who are masters in their field with emphasis on the correct

practices. The workshop shall be an open house interactive session with the delegate as the central

point.

*** IAGES MEMBERSHIP IS MANDATORY ***

If you are not an IAGES member, you may apply for the IAGES membership along with the FALS course

registration. To obtain IAGES membership, a duly filled IAGES membership form should be sent to the

conference secretariat with two passport size photographs and a separate DD for Rs. 4,000/- drawn

in the name of IAGES-Mumbai (Payable at Mumbai) as membership fee. Attach MBBS, MS / DNB

certificate (Photocopy). The conference secretariat shall forward the form to the IAGES office in

Mumbai.

Live Workshop on Laparoscopic Surgery

1. IAGES Advanced Fellowship Course

2. Assessment for Certification:

3. Eligibility for FALS Course

Non Examination Category:

The association awards fellowship to established and senior laparoscopic surgeons to recognize their

contribution in this field without examination. To qualify for this category, the surgeon should have

a minimum of ten years of experience in practice of Laparoscopy hernia surgery after post

graduation.

They are expected to have performed over 100 Laparoscopic hernia surgeries. Submission of some

evidence or undertaking is required to substantiate their claim of experience in the field of minimal

access surgery. The candidates registered in this category are required to attend all the lectures on

1st and 2nd day and live workshop on the third day. An interview of these candidates will be taken by

the IAGES board members before certification during the course. A maximum of 100 candidates can

register for this category.

IAGES FELLOWSHIP COURSE DETAILS

1. Attendance is compulsory for all course participants on all days.

2. Participants are requested to sign-in and sign-out four times a day (in & out pre lunch and in and

out post lunch) which is mandatory and stay in hall till the proceedings are over. For every in and

out a new register will be maintained. Marks will be given for the attendance.

3. Participants are requested to reach Gurgaon on 12th January evening or 13th January before 8.00

am without fail. Registration will be open on 12th January evening to avoid rush on 13th January.

4. Venue: The Meditorium, First floor, Fortis Memorial Research Institute, Sector 44, opposite HUDA

city center, Gurgaon, 122002.

6. All exam category Participants are requested to be present for the exam at the announced time on

Saturday the 14th January, 2017.

7. Participants in the non-exam category (above 10 years of experience in MAS) will appear for an

interview on Saturday the 14th evening.

8. The last sign-out will be on Sunday 2pm.

All fellowship certificates will be given only in person to the successful candidates in a convocation

Ceremony on February 2017 during the National Conference of IAGES in Hyderabad. A nominal fee

shall be charged for the convocation.

4. Instructions to Course Participants

5. Award of Fellowship Certificate

Fortis Memorial Research Institute, Gurgaon (FMRI) is a multi-super-specialty, quaternary care

hospital which has been adjudged as the second best hospital in the world in terms of technological

innovation. Set on an 11-acre campus. It has 400 functional beds, with a further planning to increase

to about 1100 beds.

About FMRI, Gurgaon :

For examination category, the candidates are required to have minimum of five years of experience

in Laparoscopic hernia Surgery after post graduation in surgery. They are expected to have

performed over 25 laparoscopic hernia procedures independently or jointly. They have to attend

proceeding of all 3 days. On the 2nd day, after the lectures, they will appear for the examination. A

maximum of 100 candidates will be registered for this course.

Examination Category:

Examination: There will be written examination on after completion of lectures. The written paper will

have 10 questions related to the topics discussed. Each question will carry 10 marks.

Total Marks: 100; Passing marks: 50

Interview and assessment on Day 3 Total Marks: 100; Passing marks: 50

Practical examination will be based on following criteria:

• Assessment of videos of hernia surgeries submitted: ** Edited videos of 10min each for Lap Ventral &

Lap inguinal hernia performed by you to be sent to us by 31st December.

• Cases shown in live workshop.

• Case scenarios for decision making.

• Publications of papers in national and international journals.

• Paper presentation in State, national and international conference.

• Conferences attended during the last five years.

• Chapters in text book / author of books.

• Other achievements / award / honors / recognitions

** The final result will be compiled after the completion of interview.

IAGES FELLOWSHIP COURSE DETAILS

Location - How to reach FMRI, Gurgaon :

• FMRI is accessible easily by road, and is located roughly 15 km from Indira Gandhi

International Airport, New Delhi. While coming from NH-8, please take exit 7 on the

highway (on the left of the flyover), go straight on the road and within 250 meters Fortis

building shall be visible from the main road. You will cross hotel Crowne Plaza and hotel

Palazio on your left.

• It can also be easily reached using Delhi Metro. The hospital is located exactly opposite

the HUDA City Centre Metro Station, the last metro station in Gurgaon.

Places of interest in Gurgaon: Kingdom of dreams , Cyber Hub, Ambience Mall,

Heritage Transport Museum, Sector 29 Market, Golf Course Road & Many Other Places.

We welcome you all to the hospital of the future.

NH-8 --- NH-8 --- NH-8 ---

Turn Left At

Exit – 7 after IFFCO CHOWK

To JAIPUR

13km

HUDA City

Center

Metro Station

Vivanta by Taj

Gurgaon

Gate No. -01

IFFCO

Chowk

REGISTRATION FEES

1. Demand draft should be made in favor of “FALS HERNIA 2017”. Payable at New Delhi.

2. To avoid postal delays send drafts early.

3. Non-IAGES member must in addition also send the form for IAGES membership with demand

draft for Rs 4,000/- drawn in favour of “IAGES-Mumbai” payable at Mumbai along with FALS

registration form to become eligible for the fellowship and avail registration fee as IAGES

members. Kindly make separate DD for membership to IAGES and for the FALS course

registration.

4. RTGS / NEFT PAYMENTS DETAILS: Current A/C name: FALS Hernia 2017 ; A/C No. “36255726467”.

SBI, ANSARI NAGAR (NEW DELHI) BRANCH, IFSC Code: SBIN0001536. Please email scanned copy

of pay in slip to “falshernia2017@gmail.com”.

5. All successful fellowship candidates will have to register for IAGES 2017 National Conference

in February 2017 at Hyderabad for award of the fellowship.

6. Documents with DD(s) should be mailed to the Conference Secretariat.

Rs. 8,000/-

Rs. 12,000/-

Rs. 8,000/-

ONLY CME AND LIVE WORKSHOP

IAGES Members

IAGES Non-members

Accompanying Person (Meals & banquets only

Not allowed to attend CME / Workshop)

Room no. 27, Lower ground floor, Fortis Memorial Research Institute,

Sector 44, Gurgaon – 122002; Tel: +91 9599425744, +91 9899224241 E-mail : falshernia2017@gmail.com

CONFERENCE SECRETARIAT

FELLOWSHIP till 15 th Dec Rs. 20,000/-

COURSE from 15th Dec till 10th Jan Rs. 22,500/-

SPOT registration Rs. 25,000/-

Recommended Reading for FALS examination

1. Comprehensive laparoscopic surgery (download from our website: www.iages.org.in)

2. Master Techniques in Surgery HERNIA, David B. Jones

3. The SAGES Manual of Hernia, Springer

4. Laparoscopic Hernia Surgery, Karl A. Feblank

Registration fee includes Conference bag, teaching DVDs, Banquet, Lunch all 3 days, refreshments and much more !!!

** Spot registration will be subject to availability

Indian Association of Gastrointestinal Endosurgeons

APPLICATION FOR MEMBERSHIP

Serial No.............................. Dated .............................

To,

The Hony Secretary IAGES

Dear Sir,

I wish to apply for active / student / associate / international / corporate

membership of the IAGES.

Personal Particulars (in block Letters)

Name................................................ ...............................................

(Surname) (first name) (middle name)

Date of birth .............Gender M/F ....Citizenship......... Passport No ...............

Permanent Address ..............................................................................

City ............................. State .............................. Pin .........................

E-mail ..................................... Website ..............................................

Telephone/ Fax ........................ City Code............................................

Office Residence

1) ......................................... 1) ......................................................

2) ......................................... 2) ......................................................

Cellular ..................... Fax No. Off ......................... Res ........................

Medical Registration No ............................ Country State/ ........................

Academic Qualification Year University/Institution

............................. .............................. .............................

............................. .............................. .............................

............................. .............................. .............................

Training In Endoscopic Surgery/Procedures

Institution Duration From (Date) Teacher

.................. .................. .................. ...................

.................. .................. .................. ...................

.................. .................. .................. ...................

Appointments/Experience

Designation Institution From To

.................. .................. .................. ...................

.................. .................. .................. ...................

.................. .................. .................. ...................

Passport

Size

Photo

Membership Of Other Associations/Societies

Association/Society Membership No.

.............................................. ....................................................

.............................................. ....................................................

I, hereby certify that the above information is correct to the best of my knowledge and I agree to Abide by

rules and bye-laws of the India Association of Gastrointestinal Endo-Surgeons,

Date ............................................ Signature .......................................

Address Of the Institution/Hospital Attachment .........................................

....................................... Tel.No ...........................Fax ............ .........

Sponsors

1. Name 2. Name

Membership No. of IAGES Membership No. of IAGES

Address: Address:

Signature: Signature:

Instruction for application. Please enclose the following:

• Attested photocopies of all certificates of academic qualification & registration

of medical council.

• Two recent colored passport size photographs

• Demand draft for Rs. 4000/- drawn in favour of "lAGES-Mumbai, payable at

Mumbai. Personal cheques, bankers cheques, etc. are not acceptable.

• Return the completed application form either to the conference secretriat or to:

• Dr. Sayandev Dasgupta

Hon. Secretary IAGES

107 Ballygunge Gardens

Kolkata - 700029

Mob: +91-9830030390

Email: sayandev.dasgupta@gmail.com

For Office Use

Application No .................. Received on ................. Submitted ..................

Approved/rejected on ................. Membership subscription of Rs./$ ............... Received on

............................. Vide cheques/demand draft No................... Dated ...................... Drawn on

..................................... Membership No ...........................................................................

REGISTRATION FORM “FALS Hernia 2017”

13th to 15th January 2017

Fortis Memorial Research Institute, Sector 44,

Gurgaon - 122002

Name _____________________________________ Age _____________Gender ______

Designation _______________________________________________________________

Address __________________________________________________________________

City ___________________ State _______________ Pin __________________

Telephone (O) __________________ (R) _________________ Mob _________________

Hospital Affiliation ________________________________________________________

E-mail ___________________________________________________________________

Draft No.: _____________Date: ___________Amount: ________________________

Drawee Bank _____________________________________________________________

in favor of “ FALS HERNIA 2017” , payable at New Delhi is enclosed.

REGISTRATION FEES: (Please tick what is applicable)

* Documents with DD must reach conference Secretariat before this date.

ONLY CME & LIVE WORKSHOP

IAGES Members Rs. 8,000/-

IAGES Non-members Rs. 12,000/-

Accompanying person(s) Rs. 8,000/-

Note: Non-IAGES members cannot apply for the fellowship. They can attend the CME & Workshop only.

**IAGES Membership No. ____________

I am not an IAGES member at present. My IAGES Membership form along with Demand draft for

Rs. 4000/- drawn in favour of "lAGES-Mumbai”, payable at Mumbai is also enclosed.

Draft No. _____________Date: ________________ Drawee Bank ____________________________________

RTGS / NEFT PAYMENTS DETAILS: SBI, ANSARI NAGAR (NEW DELHI) BRANCH,

A/C No. “36255726467”

IFSC Code: SBIN0001536 “Please email scanned copy of pay in slip to

“falshernia2017@gmail.com”

Kindly make separate DD for IAGES membership and for the course registration.

Cancellation policy: Refund request must be submitted in written. 50 percent refund if applied by Dec

31st . No refund thereafter. All refunds will be made 90 days after the conference concludes.

FELLOWSHIP till 15th Dec * RS. 20,000/- Course from 16 th Dec till 10th Jan Rs. 22,500/- (members only) SPOT registration Rs. 25,000/-

Topic preference for “Meet the Professor” (please tick any two)

Lap Ventral hernia TEP repair TAPP repair

TO BE FILLED IN ONLY BY THOSE APPLYING FOR FELLOWSHIP

*College of PG training: ___________________________________________________

*Date of Passing PG: Month __________ Year _____________

For FALS: CANDIDATE MUST HAVE PASSED M.S./ D.N.B. BEFORE Jan. 2012 (exam category) and before

Jan. 2007 (non-exam category)

*Applying for (please tick one): EXAM CATEGORY NON-EXAM CATEGORY

*Experience after MS/DNB (attach extra sheet if required): _________________

*Training Courses in Laparoscopic Surgery (attach extra sheet if required): ____

*Year of Starting Lap surgery: _____________________

*Surgeries performed every month (open plus Laparoscopic): _________________

*Number of Laparoscopic surgeries performed (attach Certificate from the Unit head/ Medical director)

*TOTAL: ______________________________Lap Hernia _______________________

*Others (Specify): ___________________________________________________

*Log book mandatory: enclose the complete list of patients with lap hernia procedures done.

Enclose DVD of two partly edited videos of Lap hernia performed by you

Conferences/Workshops attended in the last 3 years (attach extra sheet if necessary):

______________________________

Scientific Publications & presentations (attach extra sheet if necessary):

__________________________________________________________________

__________________________________________________________________

* Star marked fields are compulsory to be filled in detail.

Date: Signature:

For Office use only:-

Received Date: Receipt Sent On:

Registration No:

Room no. 27, Lower ground floor, Fortis Memorial Research Institute,

Sector 44, Gurgaon – 122002; Tel: +91 9599425744, +91 9899224241 E-mail : falshernia2017@gmail.com

CONFERENCE SECRETARIAT