MDRT DAY, Mumbai - Jan 31, 2015 A unique one day MDRT Experience like none other! Motivating and Inspirational top notch Speakers from different walks of life Main Platform Presentations that will urge you to rethink the way you prospect, sell and service clients Dynamic focus Sessions at the ConneXion Zone, where Top producers will share mantras of success So be prepared to - Adopt fresh ideas and elevate your professional and personal lives Adapt to the latest technology trends to enhance your business Aspire to leap ahead the MDRT Way! Program Highlights Open to Members, Non-members, Company Officials, Family members More than 12 powerful Speakers on diversified topics Breakfast, Lunch and Tea/Coffee breaks included Help Desk to register for MDRT 2015 Membership

1. DELEGATE REGISTRATION FORM
FIRST NAME : ____________________________ SURNAME : __________________________
INSURANCE COMPANY __________________________________________________________________
GENDER MALE FEMALE
ADDRESS ___________________________________________________________________________
_____________________________________________________________________________
CITY : ______________ STATE : ________________ PIN CODE : __________________________
CONTACT NUMBERS LANDLINE : ______________________ MOBILE : _____________________________________
EMAIL ID ______________________________________________________________________________
IF MEMBER MDRT COT TOT MDRT ID : _________________
MEAL PREFERENCE VEGETARIAN NON VEGETARIAN JAIN
PAYMENT MODE CHEQUE DEMAND DRAFT
NEFT
PAYMENT DETAILS CHEQUE / DEMAND DRAFT NUMBER : _________________ AMOUNT : _____________________
DRAWN ON BANK : __________________________________ DATED : _________________________
:
CATEGORY REGISTERED MDRT MEMBER FOR 2014 or 2015 NON MEMBER
DETAILS FOR NEFT BANK NAME ‐ IDBI BANK, BRANCH ‐ BHAYANDAR (WEST)
ACCOUNT NUMBER ‐ ________________________IFS CODE ‐ _________________________
Duly filled form along with Transac6on slip / ID (if paid by NEFT) or Cheque / Demand Dra< favouring ‐
“RIPPLEZ XPERIENTIAL MARKETING A/C MDRT DAY 2015” payable in Mumbai, to be mailed to :
Ripplez Xperien6al Marke6ng, 1st Floor, Office 33, Om Heera Panna Mall, Oshiwara, Andheri (West), Mumbai 400 053
TERMS & CONDITIONS:
1. Early bird registra6on fee 5,500/‐ (inclusive of Service Tax) up to December 15, 2014.
2. Regular registra6on fee 7,000/‐ (inclusive of Service Tax) December 16, 2014 to January 31, 2015.
3. Receipts with your Registra6on Number will be mailed to the address provided.
Kindly carry the same on the day of the event. Entry will be granted only on produc6on of the Receipt.
4. Registra6ons once done cannot be cancelled. No refunds will be provided.
Subs6tu6ons will be accepted on or before January 20, 2015.
5. The organizer reserves the right to make any amendments and/or changes to the program,
venue, speaker replacements and/or topics if warranted by circumstances beyond control.
6. Delegate fees include Conference sessions, breakfast, tea/coffee breaks and lunch.
7. 2014 & 2015 Registered MDRT/COT/TOT Members will be en6tled to Special Reserved Sea6ng.
8. Delegate fees do not include travel and lodging.
9. Confirma6on of registra6on is subject to clearance of Cheques. Out sta6on cheques should be payable at PAR in
Mumbai.
SIGNATURE : ____________________________
DATE : _____________ PLACE : _____________
0536102000014119 IBKL0000536