Date: ______

1. Title (check one): Dr. Mr. Mrs. Ms. 2. Gender: Male Female

3. Name (in Block Letters): ______

4. Father’s Name (in Block Letters): ______

5. Date of Birth: ______6. Religion: ______

7. Nationality: ______8. CNIC: ______

9. Home Address: ______

______

10. Mailing Address: ______

______

11. Telephone No.: ______12. Mobile No.: ______

13. E-mail Address: ______14. Fax No.: ______

15. Website: (if any) ______

16. Marital Status: Single: Married Divorced Separated Widowed Engaged

17. Number of Siblings: Male Female 18. Birth Order: ______

19. Family Structure: Nuclear Joint 20. Total Number of Family Members: ______

21. Residential Locality: ______

22. Type of House: Own Rented

23. Covered Area of the House in Square Feet: ______

24. House Rent (in case of rented house): ______

25. Father’s Educational Status: ______26. Father’s Occupational Status: ______

27. Father’s Designation: ______

28. Mother’s Educational Status: ______29. Mother’s Occupational Status: ______

30. Mother’s Designation: ______

31. No. of Earning Members: ______32. Total Monthly Income of Family (in rupees): ______

33. Your Employment Status: Working Non-Working

34. If Employed, Write the Name of Employer, Address, and Contact Number: ______

______

______

35. Qualification:

Exams Passed / Passing Year / Subjects / Institution / Grade/
Division / Percentage
Matriculation
F.A./F.Sc
B.A./ B.Sc.
M.A./M.Sc.
B.S.
(4-years)
M.S./M.Phil
PhD
Others

36. How many hours would you prefer to spend on this course per week? ______

37. Most significant academic/ professional accomplishments, honors and awards: ______

______

38. Cultural, educational and professional societies of which you are a member: ______

______

39. List any five Volunteer Services you ever provide:

  1. ______
  1. ______
  1. ______
  1. ______
  1. ______

40. Personal Statement: ______

______

______

______

______

41. What is your greatest Personal Strength? ______

______

42. What would you like to be able to do differently by doing this diploma? ______

______

______

43. List three things that can stop you from doing this? ______

______

44. Give any three reasons why should you be selected in this diploma program? ______

______

______

______

45. List five priorities of your life (you value the most):

______

______

______

46. What is that you can sacrifice to achieve your top most priority?

______

47. Participants have to adopt the dialysis patient and they have to apply counseling skills learned during this program on these patients. However Diploma charges of Rs. 15000/= will apply.

Cost of one dialysis is Rs.2,5 00/-. How many dialysis you can afford/adopt per month?

5, 000/- 7,500/- 10, 000/-

48. Your classes will be conducted at Dehli Medical and Dialysis Centre on Saturday (at 2:00 p.m. to 5:00 p.m.) and Sunday (at 10:00 a.m. to 1:00 p.m.). Please indicate:

  1. Location: Convenient Non-Convenient
  2. Days: Convenient Non-Convenient
  3. Time: Convenient Non-Convenient

49. Even though the classes per week are 6 hours, expect 18 hours home work. Are you comfortable with it?

Comfortable Uncomfortable

50. Have you attended any seminars of Dr. Imran? If Yes, which one?

51. Have you watched TV programs of Dr. Imran? If Yes, which one?

52. References: (List the name, title, mailing and e-mail addresses and telephone numbers of three persons who should know you very well)

  1. ______

______

______

  1. ______

______

______

  1. ______

______

______

TERMS/ CONDITIONS:

  1. Acceptance of participants is at our sole discretion and we reserve the right to refuse service and/or admission to anyone without prejudice and for any reason whatsoever and at any time.
  1. I understand this application does not guarantee enrollment in this program.
  1. Send the application form via courier latest by Dec 14th, 2012 at:

Dr. Imran Y. Muhammad

Transformation®

28-C, 4th Floor, Main 26th Street, Tauheed Commercial Area,

Phase: V. Ext. DHA, Karachi, Pakistan.

Tel: 35370880, 35370900, (0322)3746726

Email:,

OR

Preston University, Karachi

Main Campus
15, Banglore Town, Shahrah-e-Faisal,Karachi
Tel: 021-4534663-4, UAN: 021-111-707-808
Fax: 021-4525881 Email:

By my signature below, I certify that to the best of my knowledge, the information provided in this application is accurate and complete.

Signature: ______Date: ______

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