Maharashtra State OTPT Council, Mumbai St. George's Campus Hospital, Behind C.S.T. Mumbai - 400001 Ph. 22620408 Hkkx pkj& c A egkjk"v! 'kklu jkti_k] vlk-]l"vsacj 14]2007$Hkknz 23]'kds 1929 1429 uequk & vdjk FORM XI [fu;e 84(1)igk][See rule 84(1)] vfrfjdr vgzrk uksanfo.;klkbh vtkzpk uequk Form of Application for Registration of Additional Qualification izfr] izca/kd ] egkjk"v! jkt; O;olk;ksipkj o HkkSfrdksipkj ifj"kn] eqacbz- Nk;kfp_k Affix your passport size photograph To, The Registrar, Maharashtra Council for Occupational Therapy and Physiotherapy, Mumbai egksn;] egkjk"v! jkt; O;olk;ksipkj o HkkSfrdksipkj ifj"kn vf/kfu;e ] 2002 vup;s eku;rk izkir vgzrk Eg.kwu ek>;k vfrfjdr vgzrsph uksan.kh dj.;klkbh eh vki.kkl fouarh djhr vkgs- ek>ks uko o brj ri'khy [kkyh uewn dsyk vkgs %& Sir, I request you to register my additional qualification, which is a recognised qualification by the Maharashtra Council for Occupational Therapy and Physiotherapy Act,2002. My name and other particulars are stated below :
1371 Hkkx pkj& c A egkjk"v! 'kklu jkti_k] vlk-]l"vsacj 14]2007$Hkknz 23]'kds 1929 laiw.kz uko % Name in full : (BGd v{kjkr vkmukokus lqjqokr djqu 'ksovh ofmykaps$irhps uko fygkos) (Beginning with surname,and including Father's/Husband's name in block letters only) irrk % Address : fookfgr L_khps ckcrkhr R;k L_khps fookgkiwohzps uko o vkmuko (BGd v{kjkr vkmukokus lqjqokr djkoh-) Maiden name and surname in the case of married woman: (Beginning with surname in Block Letters) jk"vh!;ro % Nationality :
Hkkx pkj& c A egkjk"v! 'kklu jkti_k] vlk-]l"vsacj 14]2007$Hkknz 23]'kds 1929 1372 tuefnukad % Date of birth : iwohzp;k vgzrsps o.kzu rlsp fo kihbkps fdaok lalfksps uko % Description of earlier qualifications with name of University or Institution : nk[ky djko;kp;k vfrfjdr vgzrsps o.kzu % Description of additional qualifications sought to be added : vfrfjdr vgzrk iznku dj.kk`;k fo kihbkps fdaok lalfksps uko % The name of the University or Institution which has awarded additional qualification : uksan.kh dzekad o uksanoghpk Hkkx % Registration No. and Part of Register : uksanoghpk fnukad% Date of Registration :
1371 Hkkx pkj& c A egkjk"v! 'kklu jkti_k] vlk-]l"vsacj 14]2007$Hkknz 23]'kds 1929 jq- 1500(jQi;s,d gtkj ikp'ks iqdr) brdh vko';d rh iqh n'kzuh /kukd"kkz}kjs ikbfo.;kr ;sbzy- The requisite fee of Rs.1500 (Rupees One Thousand Five Hundered only) is sent by Demand Draft. ek>ks uksan.kh izek.ki_k o vfrfjdr vgzrsps izek.ki_k(,d lk{kakfdr izrhlg);klkscr ikbohr vkgs- d=i;k vfrfjdr vgzrsph ifj"knsp;k uksanoghr vkf.k rlsp] ek>;k uksan.kh izek.ki_kkoj uksan.kh djqu yxsp uksan.kh izek.ki_k o vfrfjdr vgzrsps ewg izek.ki_k eyk ijr dj.;kr ;kos] gh fouarh- My Registration Certificate and Certificate of additional qualification (with one attested copies)is sent herewith.i request you that this additional qualification may please be entered on the Register of the Council and also on my Registration Certificate and Original Certificate of additional qualification may please be returned to me as soon as done with. vkiyk fo'oklw] fnukad % Date : Yours faithfully, (lgh) (Signature) Hkkx pkj& c A egkjk"v! 'kklu jkti_k] vlk-]l"vsacj 14]2007$Hkknz 23]'kds 1929 1372
lwpuk% Instructions: (1) vtkzrhy loz ri'khy vtznkjkusp Hkjkok- 1. All particulars in the application shall be filled by the applicant only. (2) loz ri'khy uhv o lqokpp v{kjkr fcupwd Hkjkok- 2. All particulars should be correctly filled in a neat and legible hand. (3) vfrfjdr vgzrsph uksan.kh iqh n'kzuh /kukd"kkz}kjs HAjkoh- 3. The fee for registration of additional qualification should be sent by Demand Draft Only in favour of Registrar, Maharashtra State OT/PT Council, Mumbai.