49/24-A, Minto Road, Behind - Boy's High School, Allahabad - 211001

Ph.: 0532-2266725, 9335105694 (Office), 9839420754 (Gen. Sec. Academy)

Website: www.acusansthan-ald.in, Email: ayurved_acu@rediffmail.com
Correspondence Course
Campus Course
Enrollment No.

Center Code -
Semester - .

(To be filled by office)

Session - .

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.

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

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

Candidate Fathers/Husbands/Guardians Name (Fill in Capital Letters)

Candidate Mothers Name (Fill in Capital Letters)

Date of Birth
Sex: Male

M M

Female

Nationality
Contact No.

Students Email ID:

Permanent Address

n c o d e

n c o d e

Correspondence Address

Educational Qualifications
Name of
Board/University
Examination
Educational
Qualifications
High School

Passing Maximum
Marks
Year
Marks
Obtained

Division

Intermediate
Graduation
PostGraduation
Any Other

Documents to be attached with this form:

1.
2.
3.
4.

Certificate of 10th or Equivalent for CAHS.

Certificate of 12th or Equivalent for DAHS & ADAHS.
Other Educational certificates, if any.
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 material
particulars, I shall be liable to criminal prosecution as well as to forego my admission and to be removed
from 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 a
criminal 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:
.
Documents
to be attached with this form:
5. Mark Sheet of 10th or Equivalent.

Signature of the Candidate

Declaration to the Coordinator/Mentor:As to learn acupressure I am opting the study programme for Certificate/Diploma/Advance
Date:
..
Diploma.
Place: .
Signature of the Candidate
Endorsement by Coordinator/Mentor:Name of the Coordinator/Mentor: ..
Address of the Coordinator/Mentor: .

Signature of the Coordinator/Mentor