Fellowship Course Free

Different Types With Medical, Clinical Diagnostics and Diagnosis

Hyderbad Unit ( Redg on process )

Online International Class – Registration Form

• Revision Course Paid 8500

PERSONAL INFORMATION
Name: ____________________________________________________________________
Age: ____________________________________________________________________
Birthdate: ____________________________________________________________________
Address: ____________________________________________________________________
Status: ____________________________________________________________________
Religion: ____________________________________________________________________
Nationality: ____________________________________________________________________
Languages: ____________________________________________________________________
Email: ____________________________________________________________________
Contact No: ____________________________________________________________________

EDUCATIONAL BACKGROUND
YEAR COURSE/ DIPLOMA
__________________________________________________________________
__________________________________________________________________
WORK EXPERIENCE
YEAR NAME OF INSTITUTION/ POSITION OR TITLE
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

How did you hear about this webinar/ zoom class ?

Social Media
Word of mouth
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Others _________________________________________________________

CERTIFICATION
I, the undersigned, certify that the information submitted in this application describing my
qualifications are true and correct to the best of my knowledge.
That I understand the limitations of my practice and are subject to the laws of my country. By
affixing my signature, I acknowledge that this course aims to enhance my knowledge and skills
and in no way gives me a license to practice any part of Medicine or any means of treatment
outside the scope of my training and practice.

___________________________
Signature over printed name

Acknowledgement: ( To be filled up by the country coordinator )

This application is accepted and approved by: ___________________________________
( Signature Over Prited Name )
Participant ID number: ___________________________________