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Learning Circle 4 Registration Form
Application Form
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* Indicates required question
Email
*
Your email
State & Country
*
Your answer
PERSONAL INFORMATION
*
Dr.
Ms.
Mrs.
Mr.
Name (as on Certificate)
*
Your answer
Address
*
Your answer
Contact No.
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Languages Spoken
*
Your answer
Languages Written
*
Your answer
Current Job Description
*
Your answer
Institution & Department
*
Your answer
Educational Qualification (Year, University/College, Grade, Percentage)
*
Your answer
Fees
For members: 9000/-
For non-members: 10,000/-
The Following are the NEFT details for bank transfer (Only INR)
MAHARASHTRA DYSLEXIA ASSOCIATION
IDBI BANK
SUNNY ESTATE II
CHEMBUR, MUMBAI 400071
A/C NO.: 018104000075457 - Saving Account
IFSC CODE: IBKL0000018
SWIFT CODE – IBKLINBB004
PLEASE EMAIL THE PAYMENT DETAILS TO -
mda@dyslexiaindia.com
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