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Empowered Doctors Program - Course application form
Dream to become a doctor. Get the best coaching at most affordable cost, effective mentoring, financial assistance for MBBS, assistance for PG entrance coaching, leadership and people-management skills training.

Apply for the course most relevant for you. Selection will be based on scrutiny of the application and interview with student and parents.
Name of the student *
First and last name
Your answer
Father / Mother / Guardian Name *
Your answer
Father / Mother / Guardian Phone Number *
Your answer
Email ID (Student/parent/guardian) *
Your answer
Phone number (Student) *
Your answer
Residential address *
Please provide complete details. Incomplete details will lead to rejection of application.
Your answer
Class *
Mention the class you are currently studying.
Required
Name and address of School / College *
Please provide complete details. Incomplete details will lead to rejection of application.
Your answer
Which course are you applying for? *
Apply for the course you are most interested in. Once your application is processed, you'll be informed about the course commencement dates, venues and timings. 10th Std & 1st PU Students can apply for Course 1; 1st PU and 2nd PU students can apply for Course 2.
Required
Write a short note on what financial or other support you might require from 'Rebuild India' & 'Shraddha System of Excellence'.
Your answer
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