WNHO SEXOLOGY COURSE FORM FOR FELLOWSHIP/PG DIPLOMA.

WNHO INSTITUTE OF SEXOLOGY, PUNE INDIA

Application Form

                                                                                                Date

            Sex Therapy and Counselling Course & Skill Empowerment.

Under Govt. Recognized Startup DIPP No.3274.

Dear Sir,

I would like to enroll for the above course. I enclose Bank Draft/digital transfer No. …………………. drawn on ……………………………………………………… in favor of WNHO Healthcare Pvt. Ltd. Pune for Fellowship/PG Diploma in Sexology Fee Rs.50,000/ including GST + Hands on Training with Course Material.I give below the information requested by you.(Please use block letters and tick wherever applicable)

1. Name in full (surname first): ……………………………………….……………………………..
2. Sex:          Male (   )       Female  (   )
3. Mailing address: …………………………………………………………………………………………....

…………………………………………………………………………………. Pin Code ……………………….

Tel. Nos. Mobile ……………………..….  Res…………………………… Clinic……………………

email: ………………………………………………………………………….................................

4.    Qualifications: …………………………………………………Reg.No……………………………

5.    Registration No./Date ……………………… State …………………………….................

6.    I practice as:  Family Physician (   ), Consultant (   ), others ……………………………..

7.    My special interest is …………………………………………………………….......................

8.    I have attended: Sexuality Training Programmed (   ), Seminars (   ), Workshops (   ), No previous exposure (   ). I understand this is purely a correspondence course dealing with the essentials on sexuality concerns and problems seen in routine practice. It will be covered in eight sessions in approximately four months. 

                                                                                                            Yours faithfully,

                                                                                                                Signature

Please mail with 

Demand Draft in favor/ Ban transfer  of WNHO Healthcare Pvt. Ltd. HDFC Bank, Current account No.50200026107521. RTGS/NEFT IFSC : HDFC0000962. Payable Pune Bibvewadi Branch.

Registered Office Director-Dr. Ramesh Mahshwari, Wnho Health Care Pvt.Ltd. Web www.wnhohealthcare.com/www.sexologyinstitute.co.in.

2014 Sadashiv Peth, Dhanvantari Building, Office no.-3,

Tilak Road, Opposite ICICI Bank,Pune Pin Code 411030

Ph. 020 24463540 / 9822006427

Please enclose: 

• Photocopies of Degrees and Registration Certificate
• Self Attested passport size photograph