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Dr. V.J.S. Vohra, President
ACADEMY OF PROSTHETICS AND ORTHOTICS
Head Office: 3133, Sector 28-D
Chandigarh - 160 002, India
Adminstrative Office:
970, Sector 2
Panchkula-134112, Chandigarh, India
I submit herewith my application for membership in the grade:
1.__________________________________________ 2._________________________
Name. ..................................................................................................
Address: ...............................................................................................
Email ................................................................Tel.No...........................
Fax No....................................
Nationality ........................................Date of birth: ...................... Sex...................
Present Position/Duties ..........................................................................................
Experience in P&O/RT.................................................
Education .........................................................................
Membership of other Bodies ..............................................
Attested copies of Certificates attached or sent seperately by post/courier............................................
If handicapped, give details..............................................
Other relevant information ................................................................................. .........
DECLARATION : I hereby declare that the information given in this application is true and correct. Having read the eligibility for membership, I truthfully commit that I am eligible for the membership I have applied for. If any information is found to be false at a later stage, my membership/registration will be cancelled. I also undertake to promote the aims & objects of APO.
Date____________ Signature of applicant______________________
For Office Use: Approved for..............................................
Dated: _________________________ President
Certificate sent on : ..............................
(Checked & sent by)
Note: Relevant total fee must accompany this form.
(APO reserves its right to reject any application without giving any reason)
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