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APPLICATION FORM ( Click
here to print or save the form )
1. Name ……………………………………………………………………………………………….
(in block letters)
2. Full Address : Present
2a. Address : …………………………………………………………………………...............................
……………………………………………………………………………………………………….......
2b. Phone No. ( Including Country / Zip Code ) : …………………………………………………………………………...............................
……………………………………………………………………………………………………….......
Permanent Address: …………………………………………………………………………………………...................
……………………………………………………………………………………………………….......
3.
(a) E-mail Address :…………………………………………...............................
(b) Web Site :…………………………………………....................................
4. Age (Place & Date of Birth) ……………………………………………………………………...................................
5. a) Nationality ………………………………………………………………………………....
b) Passport No. ………………………………. Valid upto ……………………………...
c) Expected date of arriving Calcutta …………………………………………………..................................................
6. Sex ………………….............................
7. Occupation
……………………………………………………………………………………..
a) I Wish to attend Jan-Feb Programme of the year 20…..................
8. Homoeopathic experience ………………………………………………………………………
(Please state in detail, if necessary attach separate sheet) ……………
9. In case of any emergency abroad, address & telephone number where to notify
……………………………………………………………………………………………………….......
10. Amount enclosed (Advance deposit/Entire "Programme Donation")
………………………………………………………………………………………………………......
(a) Balance due ……………………… (b) Entire Programme donation to be cleared on registration in Calcutta with late fees.
I solemnly undertake to abide by the rules and regulation of the management of the Institute and maintain the peace and discipline of the Institute, failing which the management has the right to strike out my name from the Register for which no proceedings can be undertaken in any court of law.
Place ………………………..
Date ………………………..
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______________________________
Signature of the applicant in full |
* Xerox copies of credentials, two passport photographs are to be enclosed.
** US$ 100 as late fee will be charged extra for the candidates who will not reserve their place in advance by paying US$ 200 along with the application form. Such candidates may fill in the application form and enroll their names directly at Calcutta on payment of the entire Programme donation and the late fee.
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