Registration form for Hands on workshop EUS and Interventional Endoscopy

Section 1: Personal Information

Name

Date of Birth

Gender

Male

Female

Other

Address for Correspondence with City

Mobile No.

Email ID

Qualification

Section 2: Practice Setting

Practicing in

Public Hospital/ Solo

Private Hospital/Clinic

Hospital Attached

Section 3: Experience in Endoscopy

Your Experience

Section 4: Procedure Experience

Number of ERCP procedures performed till date (approx.)

Number of UGI procedures performed till date (approx.)

Number of colon procedures performed till date (approx.)

Equipment's available

Olympus

Fujifilm

Pentax

Section 4: Payment Method

Account Name : Gurukul Gastroenterologist Samiti

Bank & Branch : HDFC Bank, Shri Nagar Exte, Saket Nagar, Indore

Account No : 50100741733553

IFSC Code : HDFC0003693

MICR Code : 52240014

Amount

Transaction Date

Transaction ID