Registration – Trinetra Institute of Accupressure & Alternative Medicine

Form No :

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Name *

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Last

Father/Mother Name *

First

Last

Sex : *

Birth Date : *

Addrerss *

Nationality

Religion/Caste :

City/Town/District : *

State / Province : *

Postal or Zip Code :

Country : *

If Other Please Specify :

Phone Number *

Email *

Profession / Occupation :

Education : *

Experience (If Any) :

Idendity Card : If Required for 300 Extra

Course Name : *

Course Mode : *

Mode of Payment for Subscription : *

Message/Remark:

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.

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