ASSAM ASSOCIATION FOR PHYSIOTHERAPY

All Assam Physiotherapy Association (AAPA)

Registered under Societies Act XXI of 1860 KAM/240/A-15/884 of 2008

APPLICATION FOR MEMBERSHIP

(To be filled in block letters only)

Please enroll me as

Life Member

Ordinary Member

Student Member

in AAPA

My requisite particulars are furnished below:

Name (in full):

Father's/Husband's Name:

Sex:

Male

Female

Nationality:

Date of Birth:

Blood Group:

Educational Qualification:

Pre-Professional ( 10 +2; with the name of the board): Professional ( U.G/ P.G; with the Names of the institution and University): Further Qualifications (if any):

Working Experience (if any): Please furnish the Name of the Employers, tenure of service and the nature of the jobs.

Permanent Address:Pin Code:

Address of Correspondence:Pin Code:

Mobile Number:

Email ID:

Payment Details:

Cheque/ DD No.:

Date:

Bank:

Declaration:

I hereby declare that the above mentioned information is true to the best of my knowledge.

Date:

Place:

Photo of the Candidate

Signature of the Candidate

Submit

Assam Association
of Physiotherapy

Email

Register Here