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To Principal/Course Coordinator AIILSG Centre Please mention the name of the centre Sir I wish to join and register my name for the course POST GRADUATE DIPLOMA IN HOSPITAL HEALTHCARE MANGEMENT PGDHHM to be started from July 2011. ALL INDIA INSTITUTE OF LOCAL SELF-GOVERNMENT Admission Form for Registration-cum-Admission to the above Course. I am furnishing below my relevant details. 1. Name of the applicant Shri/Smt. /Kum* Full Name as appeared in the Degree Certificate in Block Letters 2. Date of Birth Age 3. Address for correspondence 4. Pin Code No Email 5. Telephone No* Mobile 6. Educational Qualification Examination Passed Name of the Percentage Board/University obtained Year Passing HSC Degree Other Exams Attach attested copies of the mark sheets Degree certificates duly attested by Gazetted Officer 7 IMPORTANT CONDITIONS a Course Fee Structure Non-refundable Prospectus Cost----Rs. 250/Registration Fee----Rs. 500/- Course Fee--------- Rs. 22 000/- for one Year Payment to be made at the time of Registration to the course the time of admission* b Student should indicate clearly only one address where correspondence is required to be made or documents to be sent to the student. AIILSG will not be responsible for non-receipt of documents and as such students should mention the full postal address for correspondance. c In-service students shall obtain permission if required from the employer to attend the classes and or attend the internship programme/field visits/exam as part of the training programme. AIILSG shall not accept any excuse from the in-service students on this account. Student Undertaking I have carefully gone through the procedure terms and conditions governing the admission to the course as mentioned in the prospectus along with the important conditions mentioned at clause no. 7 above. I hereby agree and accept the same. I am also aware of the eligibility conditions for the admission to the course. I am also aware that my admission to the course will be subject to the information provided by me in this admission form which I hereby confirm is factual and true. I therefore agree that if the above information full or part thereof is found to be not factual and true my admission is liable to be cancelled at my risk and cost. I am furnishing below my relevant details. 1. Name of the applicant Shri/Smt. /Kum* Full Name as appeared in the Degree Certificate in Block Letters 2. Date of Birth Age 3. Address for correspondence 4. Pin Code No Email 5. Telephone No* Mobile 6. Educational Qualification Examination Passed Name of the Percentage Board/University obtained Year Passing HSC Degree Other Exams Attach attested copies of the mark sheets Degree certificates duly attested by Gazetted Officer 7 IMPORTANT CONDITIONS a Course Fee Structure Non-refundable Prospectus Cost----Rs. Date of Birth Age 3. Address for correspondence 4. Pin Code No Email 5. Telephone No* Mobile 6. Educational Qualification Examination Passed Name of the Percentage Board/University obtained Year Passing HSC Degree Other Exams Attach attested copies of the mark sheets Degree certificates duly attested by Gazetted Officer 7 IMPORTANT CONDITIONS a Course Fee Structure Non-refundable Prospectus Cost----Rs. 250/Registration Fee----Rs. 500/- Course Fee--------- Rs. 22 000/- for one Year Payment to be made at the time of Registration to the course the time of admission* b Student should indicate clearly only one address where correspondence is required to be made or documents to be sent to the student.

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