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									                                                   REGISTRATION FORM




 1. Delegate’s Name - Prof. / Dr. / Mr. / Ms.
    First Name: _____________________________ Last Name: _____________________________
 2. Organization: ___________________________________________________________________
 3. Designation: ____________________________________________________________________
 4. Address: _______________________________________________________________________
    ______________________________________________________________________________
    City __________________________________ State ___________________________________
    Phone: _________________________ E-mail _________________________________________
 5. Registration Fees*(please tick as applicable)

                          Microfinance India Summit              Livelihoods India           Composite Registration
                                      2012                       Conference 2012                        Fees
                                           Sept. 30th                       Sept. 30th                       Sept. 30th
                          Till Sept. 30th                  Till Sept 30th                   Till Sept 30th
                                           onwards                           onwards                         onwards
   NATIONAL (INR)                  7,000       8,800                3,000        4,000              9,000       11,500
INTERNATIONAL (USD)                   400           500               190            400                530            810

 6. Payment mode
    Cheque / Demand Draft         Cash        Wire Transfer 
    Demand Draft / Cheque (within India only) Number: ___________________________________
    Dated: _________ for Rupees _____________________________________________________
    Drawn on Bank: _________________________________________________________________
    in favor of “ACCESS Development Services” payable at New Delhi.

                                                                            Registration Entitlements

                                        Participants at the Microfinance India Summit      Participants at the Livelihoods India
For wire transfer details, please       will receive:                                      Conference will receive:
contact                                  A delegate kit with 1 copy of the Microfinance    A delegate kit with 1 copy of the ‘State of
microfinanceindia@accessassist.org/       ‘State of the Sector Report’ , 1 copy of the       India’s Livelihoods Report’, 1 copy of the
livelihoodsindia@accessdev.org            Social Performance Management Report and 1         Conference Resource Book, other
                                          copy of Summit Resource Book, other                informative material from sponsors and
Please send the completed form to:        informative material from sponsors and             technical partners of the Conference
                                          technical partners of the Summit                  Lunch and refreshments
Microfinance India Secretariat/
                                         Lunch and refreshments
Livelihoods India Secretariat at
ACCESS Development Services, 28,              *ACCESS is happy to provide 30% discount on registration to the following categories:
Hauz Khas Village, New Delhi –
110016                                  Microfinance India Summit                          Livelihoods India Conference
                                        - Regional Rural Banks                             - NRLM/ SRLM
                                        - Cooperative Banks and other community            - NGOs with annual turnover of less than Rs.
                                          based organizations                                 50,00,000
                                        - CII Members                                      - Institutions eminently being supported by
                                        - Small MFIs (Portfolio less than Rs 100 cr)          sponsors of the Conference
                                        - NGOs and MFIs with Head Office in PSIG States
                                          (Odisha, MP, UP & Bihar)

								
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