Seminar Registration Form

Seminar Registration Form
:: Seminar Particulars * Required fields

Seminar Name
Seminar Date
Venue

:: Personal Particulars (Please provide either your NRIC No. or Passport No.)

Name *	Privacy Policy
National Registration Identification Card Number (NRIC No.)
Date of Birth	- -
Occupation
Gender
Marital Status
Nationality	If other nationality
Street Address 1 *
Street Address 2
Postal Code *
City *
State *
Country *

:: Contact Information (Please provide at least one contact number)

Home Telephone No.
Office Telephone No.
Mobile Phone No.
Fax No.
Email

:: Registration & Payment Information

Registration Rate
Discount Voucher Code
Choice of Food
Payment Mode *

:: Sponsor's Particulars (Program recommended to you by)

Recommended By
Contact No.

Have you been treated for : Mental Disorder Epilepsy Fainting Spells
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: I have read the above carefully and understand it thoroughly.