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"Vidhya" Application
Please fill out the form below, print and mail to

Dr. Prerak Shah
Ayurveda Counselor and Panchkarma Therapist
Silver Spring, Behind Xavier's Ladies Hostel,
Navrangpura, Ahmedabad - 380009

(Please include two passport size photographs with this application)

Dear Dr. Shah,  

I hereby wish to apply for

“Vidya” International ayurvedic training program

“Sneha” Traditional ayurvedic massage training program

“Saundarya” Traditional Ayurveda Beauty Concept training program

“Herbal Field Training program”  

I hereby wish to apply for "Vidhya" International ayurvedic training program.
I hereby wish to apply for "Sneha" Traditional ayurvedic massage training program
I hereby wish to apply for "Saundarya" Traditional Ayurveda Beauty Concept training program
I hereby wish to apply for "Herbal Field Training Program"

 Here are my details.
Personal Information: (Please write / print in capital letters)
Full Name
Address
City
State/Province
Zip/Postal Code
Country
Pin Code
Nationality
Telephone
Fax
Email
Website
Sex Male Female

Age

Birth Date (M-D-Y)

Education

Profession

Major Interests
(choose 3)

 Ano-rectal diseases
Beauty Therapy
Dermatology (skin diseases)
General medicine (Physicians)
Gynecology
Panchkarma
Provisional Education Details
Details of Institute from which you had provisional education of Ayurveda :

Basic    Intermediate   Advanced
Non-refundable registration : Euro 100 X courses = Total Euro

Payment Mode : 
Demand Draft    Personal check     Money Order    Swift    Western Union Money Transfer

Week / Month of your choice:
I abide to all rules and regulations for the education program. Yes
Interpreter
I would like to have an interpreter or translator for French-English / German - English, at an extra cost.
Date: Signature:
Please send 2 passport size photos with this application.

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