Courses

REGISTRATION FORM

Course name: _______________________________________

Last Name: ________________________________________

First Name: ________________________________________

Title(s): ___________________________________________

Date of Birth:   /   /   /

Profession: _________________________________________

Address: ___________________________________________

___________________________________________________

Phone: _____________________________________________

E-mail: _____________________________________________

Reason for taking this course: ___________________________

___________________________________________________

___________________________________________________

How did you hear about the course? ______________________

___________________________________________________

___________________________________________________

Payment enclosed in the amount of $ ______________

in the form of - circle one of the following -

1. personal cheque
2. money order
3. certified cheque

Mail your registration form and payment to:

AdiShakti

11856 Balboa Blvd #333

Granada Hills, CA 91344.

Print Name: _____________________________

Signature: _______________________________

Date:   /   /   /