Indian Institute of Health Education & Research

Total Left Seats 136

RCI Reg. No. *

Name*

Date of Birth*

Father's / Hasband Name*

E-mail*

Whats App No.*

Mobile No.*

Are you Divvyang?*

Current Address

Vill / Mohalla *

PO*

PS*

City*

Pin Code*

District*

State*

Permanent Address

Vill / Mohalla *

PO*

PS*

City*

Pin Code*

District*

State*

Same As Above

Rehab Qualification

Organization Name

Organization Address

I certify that the particulars furnished are true and complete in all aspects and no information has been withheld. I understand that falsifying documents or information on this application may result in penalties up to and including immediate/permanent dismissal for the Academy. I understand that misrepresentation, falsification of documents and/or withholding of requested information in regard to this application are serious offences that may result in prosecution. I accept that no change will be entertained once the duly filled forms have been submitted and that should my application be submitted with incomplete forms it will be rejected.

I accept that no changes will be entertained once the duly filled forms have been submitted and that should my aplication be submitted with incomplete forms it will be rejected.

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