(Please fill all details in block letters)

We (names of both participants),
1. , 2.
would like to participate in the Media Quiz organized by exchange4media Group.

Enclosed is a Cheque / DD No.   dated ,

,  favouring Adsert Web Solutions Private Limited, towards the fee.

Please select the city of your choice
Delhi Mumbai Bengaluru Kolkata
Particulars Participant 1 Participant 2
Company Name
Postal address
We have read the rules and regulations mentioned below and agree to abide by them.
Enclosed is our proof of identity and application fee.

Participant 1 ----------------------------------------

Participant 2 ----------------------------------------

Please send your forms along with the cheque/dd of the registration amount to Shivani Jamwal at
1210, Adsert Web Solutions, Kailash Building, 12th Floor, Connaught Place, New Delhi 110001
Mobile: +91 9958468898,   Phone: 011 23323184-187