Prayas Psychiatric Rehabilitation Center In Bhopal

Internship Type

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Registration Form

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Applicant's General Details

Candidate's Name:

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Candidate's DOB:

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Father's/Guardian's Name: Mother's/Guardian's Name:

Gender: Category: Nationality:

Identity Type: Identification No.: Medical History (Mental issues, Blood Pressure, Asthma):

Do you have a Domicile of M.P.?

Yes

Are you a PwD Candidate?

Yes

Are you diabetic?

Yes

Contact Details

Address

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Email Address

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Contact No.

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Alternate Contact No.

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Qualification Details

Degree Level	Degree Name	College Name	Course Stream	Final Year Status	Percentage (%)	Year of Passing/Appearing
	Bachelor College Name is required.			In Final Year Result Awaited Completed