Hands On Therapy Concepts™
Together, We Care….
B-302, Heritage Holy,
Nehru Road, PIN-400080
USC/WPS
Comprehensive Program in Sensory Integration
APPLICATION
PROCEDURE
Submit the application form
with following
- Letter
of intent- Please write on a separate sheet of paper,
your reasons for applying for this course. Include how and where you plan to apply the knowledge and other related information.
- Biodata
- License
to Practice in your home town (AIOTA,IAP,MCI registration certificate)
- Demand
draft
APPLICATION FORM
(Please
Print or Type)
Name: _________________________________________________________
Date: __________________
Home Address: __________________________________________________________
City: _____________________ State: ______________
Zip: _____________
Country: _____________
Home Phone: (_____) ____________________
Wk Phone: (_____) __________________
Cell ( ) ____________________
E-Mail (home):____________________________
E-Mail (work):______________________________
Occupation: PT___ O T___ SLP___ Other_________________(Please Describe)
I agree that the above information
is true and correct, and I agree to all of the terms and conditions contained herein, and intend to be bound thereby.
_______________________________________________ __________________________
Signature
Date