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Institutional Qualified

Personal Information

Course :-

Course Name :-

Registration Type:-

Registration Number (New) :

Registration Number (Old) :

Name of Applicant :

Father's Name :

Mother's Name :

date of birth':

Gender :

Email ID :

Mobile Number :

Aadhar Number :

Corresponding address :

Permanent address :

My Residence & Correspondence Address are same

Latest passport size image :

Nationality

Qualification Details

University/Faculty/Board :

College :

Passing Year and Month :-

Date Of First Registration :

Name of hospital or institute for purposes of teaching or research or practice, of medicine. :

Complete address of hospital or institute :

Name of person in institution or hospital who will be responsible for legal issues regarding patient care provided by doctor concerned. :

I hereby certify that the information provided above is true and correct upto my knowledge and I bear all responsibility of rejection of my application if any of the above information is found wrong. I understand that this application is a part of registration process and Board of Ayurveda is not bound to register me only by filling this form.

Personal Information

Qualification Details

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