TEACHING | TREATING | TRANSFORMING
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Full Name:
Father/ Husband/ Guardian's Name:
Date of Birth: (DD/MM/YYYY)
Gender: MaleFemale
Marital status: SingleMarriedSeparatedWidowed
Nationality:
Correspondence Address:
City
State
Country
Pin Code:

Phone Number(STD Code)

Mobile No.
Email ID:
Skype:

QUALIFICATION /EDUCATION DETAILS:

GRADUATION

Degree/Diploma/Certification:
University / School:
Month and year of passing:
Internship: name of the institute where you worked during your internship:
Registration Number:
Year of Practice:

POST GRADUATION

Post Graduate Degree:
University:
Month and year of passing:(DD/MM/YYYY)
ANY OTHER QUALIFICATIONS:
ANNUAL FAMILY INCOME: Less than Rs. 2,00,000/- per yearRs. 2,00,000/- to Rs. 5,00,000 per yearMore than Rs. 5,00,000/- per annum
WHAT EXAMPLES FROM MY LIFE MAKE ME BELIEVE THAT I HAVE THE ‘ZEAL TO HEAL’:

PLEASE ENSURE THE FOLLOWING DOCUMENTS ARE ENCLOSED WITH THIS ENROLMENT FORM-

Final Year Mark sheet. upload only jpg. file 500Kb
Degree certificate (if applicable) upload only jpg. file 500kb
Provisional Certificate (if any) upload only jpg. file 500kb
ID & Address Proof (Passport / Aadhar card / Pan Card / Election Card etc.) upload only jpg. file 500kb
Passport size photographs upload only jpg. file 500kb
STUDENT DECLARATION I solemnly declare that the above information provided by me is correct and true. I also understand that the Academy reserves the right to change any part of the course or its conditions if it considers this to be in the best interest of those concerned, and I agree to abide by the Academy guidelines and instruction

Application fees Rs 2000(refundable)
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In Case if there is difficulty in submitting form you can get in touch with us on zealtoheal@theothersong.com

Zeal to Heal Fees

Cardiology CME
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