Shakti Kriya Form

Medical History1. Are you currently suffering or have a history of any of the following health condition listed below ? If Yes, please provide the details.

Medical Declaration

2. Do you have any problems with your legs?

Asthma,Epilepsy,BP,Heart Problem,Back Pain,Walking Difficulty,Obesity / Highly Overweight,Pregnancy,Spondylitis,Disc Problem,Arthritis,Knee pain,Glaucoma,Hip & Knee replacement done,Vertigo,Any bleeding,HIV.

3. Have you undergone any surgery I the recent past ?

4. Are you taking any prescribed medicine for any physical ailment or health condition ?

5. Are you taking any prescribed medicine for any mental health condition ?

I declare that all the above information provided by me is correct. I also understand that my entry into this program will ONLY be authorised after clearance of the medical health check-up upon arrival at the Denpasar Bali, Indonesia

By tick on I AGREE below, you confirm that you have read the Medical Declaration and AGREE with it.

I AGREE

Shakti Kriya Form

Course HistoryNumber of Advance Courses

Course (Please Tick) :

First Advance Course Date :

Place :

Teacher Name :

Course (Please Tick) :

Part 2/AMC - Navratri

Part 2/AMC - 10 Days

Part 2/AMC - 4 Days

Part 2/AMC - 5 Days

Part 2/AMC - 7 Days

Part 2/AMC - Yes ++

Last Advance Course Date :

Place :

Teacher Name :

Part 2/AMC - Navratri

Part 2/AMC - 10 Days

Part 2/AMC - 4 Days

Part 2/AMC - 5 Days

Part 2/AMC - 7 Days

Part 2/AMC - Yes ++

Shakti Kriya Form

Personal Details

First Name

Middle Name

Last Name

Gender

Date of Birth

Marital Status

Professional Details

Profession

Are you an Art of Living Teacher

Mobile Phone

Primary email

Adress

Country

State

City

Shakti Kriya Form

Accomodation Preference

Preferred Accomodation Type

Select Room Type Contribution Include meal and accomodation

Course Date 19th - 20th April 2014 (check in 18th April '14)

Hotel Grand Inna Bali Beach / Plaza Bali Paradise

Twin shareSingle

USD 400USD 600

WE HAVE 2 OPTION OF BANK (wire)TRANSFER :

Beneficiary Bank and Address : BANK OF INDIA,

SINGAPORE BRANCH, SINGAPORE

SWIFT CODE : BKIDSGSG

Beneficiary Name :

YAYASAN SENI KEHIDUPAN / ART OF LIVING

Beneficiary Account Number :(USD) 5359300102

Beneficiary Bank and Address : Bank MEGA ,

Branch Hasanudin, Jakarta Selatan,Indonesia

SWIFT CODE : MEGAIDJA

Beneficiary Name :

PT Sri Sri Yoga

Beneficiary Account Number :(USD) 01.023.20.11.88886.1

Please follow below instruction:1. Fill in your full name and your ID number in the receipt which is generated once you register (VERY IMPORTANT) in your Bank Receipt (message box) and Subject email2. Pay in FULL AMOUNT3. Scan the Registration & Accomodation form and TT (bank transfer receipt) copy and email it to info@artofliving.or.id4. An email of confirmation will send once your payment is received in our account.5. Please send us your Bank Transfer Copy Within 4 days of your registration or your booking will get cancelled by system automatically.

*Participant who have Registered Shakti Kriya (Include Bhagavad Gita Discourse)