Programs Application Form

Name (in capital):

Address (permanent):

Date of Birth:

Daughter/Son/Spouse of:

Phone Number:

Email:

Country:

City:

Nationality:

Caste:

Gender:

Occupation:

HO Code (Optional):

Marital Status:

Photo (JPEG or PNG only) (Maximum size 5MB):

Identity Proof (PAN Card, Driving License, Voter ID Card)(Self attested JPEG or PNG only) (Maximum size 5MB):

Residential Proof (Aadhar Card)(Self attested JPEG or PNG only) (Maximum size 5MB):

Program Name:

Duration of the Program:

Program Fee (including registration fee/food/lodging/whole body check-up/medicine):

SELECT PAYMENT MODE:

1. FAST PAY SERVICE:
ONE TIMEINSTALMENT BY MONTHLYINSTALMENT BY WEEKLYPrime Membership

2. BELOW POVERTY LAUGHTER:

3. GO-BUSINESS BLUE:

WHY I WANT TO PURSUE THIS PROGRAM?

DECLARATION

I, SRI/SMTI SON/DAUGHTER OF/ SPOUSE OF declare that the information given in this application is true and correct to the best of my knowledge and belief. I am pursuing this program with all my consent and no one is liable for this but me. And also I hereby declare that I will abide by all the rules and regulations of this Hospital whatever provided during the program. In case any information given in this application proves to be false or incorrect and if I will violate any sort of rules and regulations of this Hospital during their observations then I shall be liable by the law of jurisdiction and take all responsibilities for the consequences.

PLACE:

DATE:

(SIGNATURE)

(GUARDIAN SIGNATURE)

I, hereby, confirm that I have carefully read and fully understood the Terms and Conditions governing the use of (service/product), and I hereby accept and agree to be bound by all of its provisions.

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