INTERNATIONAL INSTITUTE OF ACUPUNCTURE

“Saraswati Niketan”, Ramsagarpara, Raipur – 492001 (C.G.), INDIA

Ph. 91-771-2292070 (Clinic), 2284077(R), 094252 - 07766(Mobile)

 APPLICATION FOR REGISTRATION

1. Name :

    (In Block Letters)                       Surname                    First               Second

 2. Father’s/Husband Name

 3. Date of Birth

                                                            Day                             Month            Year

 4. Address     (1) Present

                         (2) Permanent

                         (3) Telephone           STD Code                  Office             Residence

 5. Nationality

 6. Professional Qualification in Detail

   & Photostat copy of Diploma/Degree

 7. Specialisation  if any

 8. Experience

 9. Peresent Professional Status

 10. Language Known :-

                        [1] Written

                        [2] Spoken

 11. Any other information

 I declare that the above mentioned particulars are true. I have persued the terms & conditions laid down by center. I am prepared to abide by them.

 Date    :

Place  :

Encls  :

                                                                                                                        Signature