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INSTITUTE OF COMPLEMENTARY MEDICINE(ICM) Affiliated-IBCM-INTERNATIONAL BOARD OF COMPLEMENTARY MEDICINE & GLOBAL EDUCATION(WNHO) AUTONOMOUS EDUCATIONAL TRUST REGISTRATION NO.382/11985 GBBSD BPT 1950F-10581, MUMBAI. APPLICATION FORM I wish to apply for online certificate courses 1) Diploma in cosmetology and Dermatology , Laser. 2) Diploma in Sexology and Psychosexual medicine. Name-............................................................................................................. Age ....................... Address........................................................................... ......................................................................................................... ............................................................................................................. ............................................................................................................. Date of Birth-...........................................Mob-.............................................. Email-.................................................................................. DECLARATIONS. I hereby declare that the above information is true. I have read the rules of discipline. I agree to fully abide by them and also rules made by the authorities of the institute from time to time .I know that fees once paid will not be refund or transferred on any account. further I, wish to begin this unique course for my Skill enhancement . I cannot prescribed any medicine unless and until I had registration in that Branch. Signature of student. Address Course Co-Ordinator WNHO clinic, Sadashiv Peth, Opp ICICI Bank, 3 Dhanwantari Building, Tilak Road, Pune-411030 , Mob-9822006427 Email:drrameshm2@gmail.com Website: www.wnhohealthcare.com/www.wnhocare.co.in