COURSE APPLICATION FORM Passport Size

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Form / Reg. No. __________ Date_______________ Only One
Attach

I wish to register myself for (Name of course).............................................................................................

Name (In Block Latter) ____________________________________________ Sex – M.../F...

Father's/Husband's/Guardian's Name ___________________________________________________________

Permanent Address_________________________________________________________________________

City/Town/Work Place/District__________________________State___________________Zip/Pin_________

Correspondence / Present Address _____________________________________________________________

City/Town/District __________________________ State _______________________Zip/Pin_____________

__________________Mobile __________________E-mail______________________________________

Religion/Caste____________Blood Group____Website/FB_________________________________________

Date of Birth __________Age____ Nationality ___________ Profession/Occupation_____________________

Educational Qualification ________________________________Additional Qualification________________

Experience (If any) ___________________________________Language Medium-Hindi__/ English__/Other_

Course Mode: Regular ___ Camp___ Distance Learning : Correspondence___ Internet-Email____Online____

Reading Material Send by – Regd. Post...............Courier............by Hand..............E-mail..............In Class..........

Identity Card______ (If required fees Rs 300 Extra) Recommended by_______________________________

Name & City as you wish on Certificate_________________________________________________________

Attached Documents List_____________________________________________________________________

Subscription: Payment Mode-Cash/Bank/E-M.O./Cheque/Paytm/Net Banking/Online/Other________________

AXIS Bank, Acupressure Research, Training & Treatment Institute, Jodhpur A/C No.057010100177573

This is to confirm that I wish to enroll myself for the course. I hereby declare that above information is true
to the best of my knowledge.
Your faithfully
For Office Use : Check by................ C. D. Sign.…………

Remarks...................................................................................... (Signature of Applicant)