8/19/2019 Academy Form

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Center Code - ………… 

Semester - ……………. 

Session - ………………. 

Enrollment No. 

(To be filled by office) 

(Particulars to be filled in correctly and legibly by the candidate) 

Candidate Name (Fill in Capital Letters) as per record of Matriculation Cert. 

Date of Birth  Nationality  

Student’s Email ID: 

Sex: Male Female  Contact No.

Permanent Address

P I n c o d e

49/24-A, Minto Road, Behind - Boy's High School, Allahabad - 211001Ph.: 0532-2266725, 9335105694 (Office), 9839420754 (Gen. Sec. –  Academy)  

Website: www.acusansthan-ald.in, Email: ayurved_acu@rediffmail.com

Candidate Father’s/Husband’s/Guardian’s Name (Fill in Capital Letters) 

Candidate Mother’s Name (Fill in Capital Letters)

Correspondence Address 

P I n c o d e

Certificate in Acupressure Healing Science (CAHS) –  Corr. /Camp. 

Diploma in Acupressure Healing Science (DAHS) –  Corr. /Camp. 

Advance Diploma in Acupressure Healing Science (ADAHS) –  Corr. /Camp. 

D D M M Y E A R

Correspondence Course

Campus Course

8/19/2019 Academy Form

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Educational Qualifications

Documents to be attached with this form:

1.  Certificate of 10th or Equivalent for CAHS.2.  Certificate of 12th or Equivalent for DAHS & ADAHS.3.  Other Educational certificates, if any.4.  One passport size recent photograph extra.

Declaration by the Candidate:

1.  I have read the Rules and Regulations regarding the concerned programme.2.  I do solemnly affirm that the statement and information furnished by me as above and also in the enclosure

submitted are true. I realize that if any information furnished therein is found to be untrue in materialparticulars, I shall be liable to criminal prosecution as well as to forego my admission and to be removedfrom the College. If already admitted, I shall abide by the decision of the Director/Principal.

3.  I also undertake to pay the College, Hostel and other dues prescribed by the College on due date.4.  I also declare that:

I have not been convicted of any criminal offence nor have been released on bail in connection with acriminal case.No case of criminal offence or moral turpitude is pending against me in any Court of Law.No complaint or FIR has been lodged against me.I have not been debarred from appearing in any of the Entrance Exam / Public Examination.

Date: ………………………………………….. 

Place: ………………………………………….

 

Signature of the Candidate 

Name of

ExaminationBoard/University

Passing

Year

Maximum

Marks

Marks

Obtained% Division

High School

Intermediate

Graduation

Post-

Graduation

 Any Other

Declaration to the Coordinator/Mentor:-

 As to learn acupressure I am opting the study programme for Certificate/Diploma/Advance

Diploma.

Endorsement by Coordinator/Mentor:-

Name of the Coordinator/Mentor: …………………………………………………….………………………… .

 Address of the Coordinator/Mentor: ………………………………………………………………….………… 

Signature of the Candidate 

Signature of the Coordinator/Mentor