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Full Name(as required on the certificate)*

Email Id*

Mobile No.(whatsapp Number only without country code)*

Gender*

Meal preference*

Institute*

Address*

Country*

City

State*

Category*

Do you want attend Workshop? *

Payment Mode*

Amount*

Bank Details:
Account Name: LASACON 2025
Account No: 8089621212
IFSC Code: IDIB000G085
Bank Name: Indian Bank
Branch Name: Indian Bank GITAM University

UTR Id / Transaction Id.*

Transaction Date *

Upload Payment Receipt *

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