Farmer's Dialogue 2014, India - Application Form
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Title *
First Name *
As it is in Passport
Middle Name
As it is in Passport
Last Name *
As it is in Passport
Gender *
Passport Number *
Country of Issue *
Visa Number
Passport Expiry *
MM
/
DD
/
YYYY
Nationality *
Country of Origin *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Phone Number *
With Country Code
Mobile Number *
With Country Code
E-mail Address *
Occupation *
City *
Sponsoring Organization
Date of Arrival *
MM
/
DD
/
YYYY
Date of Departure *
MM
/
DD
/
YYYY
Flight Details *
Flight No./Flight Arrival Date/ City of Arrival/ Flight Departure Date/ City of Departure
Reference Person *
Meal Preference *
Bio / CV *
Expectations from Dialogue *
Would you like to make a presentation ? *
If yes, please give the description of the subject
Your total expenses *
Your Personal Contribution *
Amount you can raise *
Shortfall *
While we do not have ready funds we will attempt to raise some funds.
Registration Charges
Registration Charges are $250per person. (To be paid in USD)
How would you like to contribute.
Clear selection
All Cheques / Demand Draft to be drawn in favor of " Comptroller Dr.PDKV Akola"
Fax Number. (if any)
How would you like to contribute *
All Cheques / Demand Drafts to be drawn in favor of "Friends of Moral Re-Armament, India"
Bank Transfer details are as below :
Name of the Account Friends of Moral Re-Armament (India)
Name of the Bank         IDBI Bank
Name of the Branch Panchgani Branch
Address of the Branch  Shopping Complex, Main Road
                              Panchgani - 412805
                              Dist. Satara, Maharashtra
Account No.              47710010000372
Account Type              Savings Bank Account
IFSC Code of the Bank  IBKL0000477
MICR Code 700259477
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