REGISTRATION FORM

Please copy this form into your compose box in your email and
fill this and then, send to our mail (chudamanigiri@iom.edu.np)

Registration Form

“Asian Students’ Meet-A Call from Medical Community
for Prevention of Small Arms Violence”

1. PERSONAL INFORMATION:

*Requested fields

Name:*………………………………………
Surname:* ………………………………………
Gender:* Male/Female
E-mail:* ………………………………………
Mobile phone: ………………………………………
Address:* ………………………………………
City:* ………………………………………
Country:* ………………………………………

Did you participate in any former PSRN Programs?* Yes/No

Foreign participants (except Indian Nationals) are obliged to enter passport number and passport expiration date!
Passport No: ……………………………………… Expires on: ………………………………………

2. INSTITUTION INFORMATION:

University:* ………………………………………
Faculty:* ………………………………………
Are you a student:* Yes/No
or a young doctor:* Yes/No
If you are member of any student association, please specify: ………………………………………

3. ARRIVAL AND ACCOMMODATION INFORMATION:
Arriving on: ……………………………………… with Bus/Aero plane
Expected Days of Stay: ………………………………………
(If you want to stay longer than the program schedule, please mention)

4. PRESENTATION INFORMATION:

Presentation topic: Activities of Students in your country Small Arms Others (Please Specify) ………………………………………
Presentation type: ……………………………………… (MS PowerPoint or any other means)

5. OTHER INFORMATION:

Are you interested in any of the following? Please specify …………………………………………………
(Trekking/Sightseeing/Rafting/Mountain Biking/Tour Package/Social Interaction)
Diet type:* Regular Vegetarian
Special needs: …………………………………………………………………………………………………
Any comments? ………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

For all other information do not hesitate to contact our mail: chudamanigiri@iom.edu.np