INDIAN INSTITUTE OF

COUNSELLING

Post Graduate Diploma in Psychological Counselling

Application Form

Full Name: _____________________________________________

Sex: __________________ Date of Birth: ____________________

Attach Photo Here

Ph Number: ____________________________________________
Email: ________________________________________________
Permanent/Mailing Address ___________________________________________
__________________________________________________________________
State: _________________________ Pin Code: ___________________________
Application Date: ____________________________ Year of Enrollment:
_________________
Education Qualification:
DEGREE

UNIVERSITY

YEAR

SUBECT/COURSE

INDIAN INSTITUTE OF COUNSELLING

B-83, BASEMENT, GULMOHAR PARK
NEW DELHI, 110049
09818854460, 011-4614-0405
www.indiancounselling.com

PERCENTAGE/DIVISION

Employment Details: (Current Tick appropriate)

Student __________
Homemaker ___________
Currently unemployed __________
Employed: ________Designation:
______________________________________________________
Company/Organization:
_____________________________________________________________
Office Address:
________________________________________________________________________
Ph.: _____________________________ Office website:
______________________________________
Certificates: (List all certificates attached)
________________________________________________________________________
__________________
________________________________________________________________________
__________________
________________________________________________________________________
__________________
________________________________________________________________________
__________________
I acknowledge that the above details are accurate

INDIAN INSTITUTE OF COUNSELLING

B-83, BASEMENT, GULMOHAR PARK
NEW DELHI, 110049
09818854460, 011-4614-0405
www.indiancounselling.com

(Applicant Signature)
(Date)

INDIAN INSTITUTE OF COUNSELLING

B-83, BASEMENT, GULMOHAR PARK
NEW DELHI, 110049
09818854460, 011-4614-0405
www.indiancounselling.com