Further Your Education for Free

Advanced Institute of Neurosciences -

Hyderabad unit

Online Program –Registration Form

( ) FELLOWSHIP
( ) DIPLOMA COURSE

PERSONAL INFORMATION
Name:
Age:
Birthdate:
Address:
Status:
Religion:
Nationality
and
Language:
Email:
Telephone
No:

EDUCATIONAL BACKGROUND
YEAR COURSE/DIPLOMA

WORK EXPERIENCE
YEAR NAME OF INSTITUTION/ POSITION OR TITLE
Further Your Education for Free

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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.

Wiwit
Wiwit Fitriya, Signature over printed name (Surname, First
October 27, 2020 Name, Middle Name)

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

This application is accepted and approved by:

(Signature Over Printed Name)

Participant ID number: