Please submit your application in following format

Application Form

(USE CAPITAL LETTER ONLY, all fields must be filled) 

Name: ____________________________________                      Recent Colored

Date of Birth____________________ Gender ____                       Passport Size

Qualifications: _______________________________                        Photograph

Name of the Institution Passed From ________________

(Only Qualified PT / students from a recognized Institute is eligible)

Mailing Address (Present) ___________________________________________

Street__________________________________City_______________________

State_______________________Country________________PIN_____________

Ph: (Res.) _________________________ Ph: (Mobile) _____________________

Ph: (Work) ____________________________ Email: _____________________

Work Address (Present) ____________________________________________

Street _________________________City______________________________

State______________________Country________________Pin_____________

Fee Detail: Rs. ____________ D.D. No. _____________ Bank: _____________  

City & Date (you wish to attend this workshop) ___________________________

Details of other Manual Therapy courses done earlier (If any).

Instructor’s Name________________ Course Location _________Date_________

Instructor’s Name________________ Course Location _________Date_________

 This is to certify that I am not suffering from any known medical illness, which stops me to undergo manipulation. So I am fit to undergo manipulation & mobilisation for any part of my Body.

Signature of Applicant

With Name, Date & Place.