LIFE INSURANCE ROUND TABLE
211, Nav Neelam C.H.S. R.G. Thadani Marg, Above Sadanand Hotel Worli, Mumbai-400 018
Tel:(91-22) 24913369/66623966 TeleFax:66669228 E-MAIL:lirt@hathway.com  WEBSITE: www.lifeinsuranceroundtable.org 
25th SILVER JUBILEE CONVENTION
Please stick
the
photograph
of attending
participant
SEPTEMBER 1st-3rd, 2012, PRE-CONVENTION 31st August, 2012
THEME: Win And Shine
VENUE: First World - Genting, Malaysia
NAME:*
ADDRESS:
STATE:
PIN:
STD CD:
(R):
(O):
FAX:
MOBILE:
PAGER:
E-MAIL ID:
2010 LIRT REGISTRATION:
Choice of Room Partner:
Headphone (Hindi Translation):
Note : Please Staple Passport Size Photographs
DATE OF BIRTH: (dd/mm/yyyy)
QUALIFICATION:
COMPANY NAME:
DESIGNATION:
DATE OF APPOINTMENT: (dd/mm/yyyy)
AGENCY CODE NO.:
BRANCH:
DIVISION:
CLUB Membership:
MDRT: TIMES QUALIFIED ATTENDED:
LIRT: TIMES QUALIFIED ATTENDED:
FIRST TIME ATTENDEE :     
FOOD :    
 
 
QUALIFYING CONDITIONS:
1. Rs. 5, 00, 000/- First Year Commission with Bonus from 1.4.2011 to 31.3.2012
   40% Credit for Personal Accident and Mediclaim commission only for above.
2. 65% of all the above conditions for the Rural Area agents and agents aged 65 years and above.
Certifying Letter from Branch Manager of F.Y. commission with bonus from 01.04.2011 to 31.03.2012
 

Star Agent: Rs. 12,00,000/- (F. Y. Commission with Bonus) } Special felicitation.
Twinkle Star: Rs. 24,00,000/- (F. Y. Commission with Bonus)
Managers Session: (Exclusive) 31st August, 2012.  

Dues: Participation Fees: (Includes Registration, Air Fare, Stay & All Meals)
(Non-refundable)		 On or Before
Rs. 40,000/- 20.01.2012
Rs. 45,000/- 31.03.2012
Registration close after 30th April 2012
 
I hereby certify that I will adhere to the code of ethics of Life Insurance Round Table
Sign :_______________________ Paid : Rs._________________ Cash / DD No.____________
Dated_______________________ PAYABLE BY BANK:______________________________________
Cheque for the participation fees is to be written in favour of "LIFE INSURANCE ROUND TABLE".
 
For Office Use :
Approved / Declined  
President / Vice-President /Secretary Signature:_________________________________________
   
Rights reserved for the approval & membership solely with LIRT Committee.