COURSE REGISTRATION FORM

Name: AS REQUIRED ON CERTIFICATE. KINDLY USE BLOCK LETTERS

_______________________________________________________________________________

Address (Present) ________________________________________________________________

Street_________________________________________________City_____________________

State________________________________Country_____________________PIN____________

Qualifications: __________________________________________________________________

Institution Passed From ___________________________________________________________

Mobile No.: __________________________Alternate Contact No.:________________________

Email: _________________________________________________________________________

Name(s) and Date(s) of course(s) interested in: ________________________________________

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Food preference:  ________________________________________________________________                 

Food Allergies (please specify if any) ________________________________________________

Payment mode (Please tick)

•	Cash (Amount)____________ 

•	DD/Cheque No. _________________Dated_______________ Amount________________ 

Drawn on_________________________________________________________________ 

•	Direct Deposit (Amount)___________________________________(Please attach receipt) 

•	NEFT/RTGS Amount______________ Transaction Reference No. _____________________ 

Wire transfer details – Account Name – PHYSIOREVIVE, Bank Name – ICICI Bank , New Rohtak Road Branch, Karol Bagh, New Delhi -110005, INDIA, Account Type – Current,  Account Number – 071505500437,  IFSC Code: ICIC0000715 Cheque/DD to be drawn in favour of “PHYSIOREVIVE” payable at New Delhi
Kindly Email or WhatsApp this form along with the copy of Payment receipt on +91 98102 27127, 9818916127
Email. physiorevive@gmail.com

Terms – No video recording allowed. Fees non‐refundable unless event is cancelled. Migration from one program to another not allowed. Organizers reserve the right to reschedule the program if required.

PHYSIOREVIVE, B-4/169-C, Keshav Puram, New Delhi -110035, INDIA, Phone: +91 98102 27127, 9818916127 www.physiorevive.com Email: physiorevive@gmail.com or info@physiorevive.com
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