Tel : (010) 64130582, 4000-650-970, 13661058751,   

 

Email: paidalajin123@gmail.com  

 

If you’d like to attend a workshop, please fill in the registration form below and send it to the above email

 

Paida and Lajin Workshop Registration Form

 

* Please fill in the form below. Do not leave the spaces blank. Fill in N#A if you cannot provide relevant information.

 

Workshop Duration:

 

From _____________________________ (month/date/year)

 

To _____________________________ (month/date/year)

 

Given Name:

 

Family Name:

 

Gender:

 

Age:

 

Valid ID NO.:

 

Valid passport No. & Nationality or Other Documents: 

 

Current Employer:

 

Professional Title: 

 

Home Tel.:

 

Office Tel.: 

 

HP:

 

E-mail:  

 

Address & Postal Code:

 

 

Source of Information about the Workshop:

 

(√) Internet ( ) Books ( ) Messages ( ) Friends ( ) Others: ____________________

 

 What health problems do you have? (√)

 

Neck problem ( ) Lower back and leg pain ( ) Constipation ( ) Frozen shoulder ( ) Insomnia ( ) Obesity ( ) Heart problem(s) ( ) High blood pressure ( ) Diabetes ( ) Gynecological / prostate disorders ( ) Others: __________________________

 

I hereby state that 

1) The above information is true and accurate;

2) I shall bear all the consequences resulting from false information. 

 

Applicant’s Signature:_________________________________________________ 

(*Registration deemed unsuccessful without the signature above.) 

 

Date: ____________________________ (month/date/year)

 

 

May you always enjoy good health and happiness!