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!