Seminar Registration Form |
:: Seminar Particulars * Required fields |
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Seminar Name |
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Seminar Date |
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Venue |
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:: Personal Particulars (Please provide either your NRIC No. or Passport No.) |
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Name * |
Privacy Policy |
National Registration Identification Card Number (NRIC No.) |
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Date of Birth |
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Occupation |
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Gender |
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Marital Status |
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Nationality |
If other nationality
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Street Address 1 * |
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Street Address 2 |
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Postal Code * |
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City * |
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State * |
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Country * |
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:: Contact Information (Please provide at least one contact number) |
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Home Telephone No. |
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Office Telephone No. |
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Mobile Phone No. |
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Fax No. |
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Email |
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:: Registration & Payment Information |
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Registration Rate |
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Discount Voucher Code |
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Choice of Food |
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Payment Mode * |
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:: Sponsor's Particulars (Program recommended to you by) |
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Recommended By |
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Contact No. |
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Have you been treated for :
Mental Disorder
Epilepsy
Fainting Spells
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I, the undersigned, hereby pledge to use my knowledge of Silva Method in strict accordance with
the laws of Malaysia & United States of America (USA). Especially I will not use the Silva Method
for therapeutic purpose unless I am a licensed physician or psychologist and strictly within the
supervising practitioner's areas of competence. Further, I agree to save Silva International, Inc.
and / or their authorised representatives, harmless from any liability for any intentional or
unintentional misuse of The Silva Method on myself and on others by me.
I understand that at the completion of the program if I am not satisfied, I would request from my
facilitator a refund of my program fee within three days. The program fee, less food and beverage
charges, will be refunded within one month. My acceptance of my certificate will signify my
satisfaction and my waiver of the money back guarantee rights.
We value our relationship with you and would not sell or disclose your personal information to a
third party. We would like to communicate with you on our seminars, notices of events and products
which we think may interest you from time to time. Please inform us otherwise.
Please check the box below:
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