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Dr Robin Mann
Suresh Lulla
About BestPrax Club
Venue Details
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Registration Fees
Registration Fee - INR 10,000 + 15% Service Tax = INR 11,500
Payment should be made by At Par Cheque/Demand Draft in favour of ‘BestPrax Club Pvt. Ltd.’ and couriered to:
BestPrax Club Pvt. Ltd., 4B Sindhu House, Nanabhai lane, Fort, Mumbai - 400 001
Nominating Authority
Title*
First Name* Last Name*
Designation*
Company*
Site / Unit
Address*
City* Pin*
STD Code* Phone*
Direct Number Mobile*
Official Email* Personal Email
Nominations
1. Title*
Name*
Designation*
Site / Unit
Address*   same as above
City* Pin*
STD Code* Direct Phone*
Mobile*
Official Email*
Personal Email
2. Title
Name
Designation
Site / Unit  
Address   same as above
City Pin
STD Code Direct Phone
Mobile
Official Email
Personal Email
3. Title
Name
Designation
Site / Unit  
Address   same as above
City Pin
STD Code Direct Phone
Mobile
Official Email
Personal Email
4. Title
Name
Designation
Site / Unit  
Address   same as above
City Pin
STD Code Direct Phone
Mobile
Official Email
Personal Email
5. Title
Name
Designation
Site / Unit  
Address   same as above
City Pin
STD Code Direct Phone
Mobile
Official Email
Personal Email
Total Amount Due: