Fields marked with * are mandatory
Payment Mode *	Credit Card/Debit Card   Cheque/Demand Draft   Neft/Demand Draft
Your Name*
Your Email*
Designation*
Company*
Phone No.
Mobile No.*
Address*
Number of Delegate*
Amount*
Mode of Payment*	Credit Card (master / Visa)
Fees & contact details will be: One Delegate                       Rs. 6,000 5-10 Delegates                     5% Discount 11-20 Delegates                   10% Discount 21-50 Delegates                    15% Discount More than 50 Delegates       20% Discount
Cheque/DD to be sent in favour of “Adsert Web Solutions Pvt Ltd” And send to Prateek Goyal 301, Kakad Bhavan, 3rd Floor, 11th Street,Opp. Galaxy Cinema, Bandra West, Mumbai 400050 PH: (022) 66206000 This should to be accompanied by the cover letter mentioning Pitch CMO Summit 2017 Delegate Fees. For any queries related to Registration, contact: Prateek Goyal: prateek.goyal@exchange4media.com, +91 9769124432