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Tel : (010) 64130582, 4000-650-970, 13661058751, Â Â
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Email: paidalajin123@gmail.com Â
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If you’d like to attend a workshop, please fill in the registration form below and send it to the above email
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Paida and Lajin Workshop Registration Form
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* Please fill in the form below. Do not leave the spaces blank. Fill in N#A if you cannot provide relevant information.
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Workshop Duration:
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From _____________________________ (month/date/year)
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To _____________________________ (month/date/year)
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Given Name:
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Family Name:
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Gender:
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Age:
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Valid ID NO.:
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Valid passport No. & Nationality or Other Documents:Â
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Current Employer:
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Professional Title:Â
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Home Tel.:
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Office Tel.:Â
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HP:
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E-mail: Â
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Address & Postal Code:
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Source of Information about the Workshop:
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(√) Internet ( ) Books ( ) Messages ( ) Friends ( ) Others: ____________________
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 What health problems do you have? (√)
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Neck problem ( ) Lower back and leg pain ( ) Constipation ( ) Frozen shoulder ( ) Insomnia ( ) Obesity ( ) Heart problem(s) ( ) High blood pressure ( ) Diabetes ( ) Gynecological / prostate disorders ( ) Others: __________________________
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I hereby state thatÂ
1) The above information is true and accurate;
2) I shall bear all the consequences resulting from false information.Â
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Applicant’s Signature:_________________________________________________Â
(*Registration deemed unsuccessful without the signature above.)Â
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Date: ____________________________ (month/date/year)
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May you always enjoy good health and happiness! Â Â
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