Registration form Indonesia

Registration form Indonesia

To book and secure early bird discount, kindly fill in registration details and specify payment method and e-mail back within 48 hours. Payment can be made via bank transfer, cash on the day with prior agreement, cheque with prior agreement or on-line booking with credit card. Registration details can be sent back on the attached form or via e-mail by filling the below details. 

First Name______________________________________________________

Last Name______________________________________________________

Name to be written on Certificate (if different from above)

_______________________________________________________________

Profession_______________________________________________________

Date of birth______________________________________________________

Preferred contact phone number________________________________________

Permanent e-mail address______________________________________________

Postal Address______________________________________________________________

City_____________________________       State/County_____________________

Pincode/Zipcode __________________        Country_________________________

Primary reason for attending course, for example personal development, self healing, become a Practitioner ______________________________________________________________

How did you find out about our training, for example newsletter, facebook, website________________________________________________________

Special needs, for example special diet, wheel chair access ___________________

Preferred Payment method:

Cash on the day – YES/NO

On-line bank transfer (India account)- YES/NO

On-line bank transfer (UK account) – YES/NO

On-line booking link via credit card, upto plus 4% – YES/NO

Paypal, plus 3% service fees – YES/NO

Payment to be made by (date) ________________________________

Bank Transfer to Vitality Living UK 

Account name: Rangana Choudhuri

Bank Name: HSBC (Hongkong Shanghai Bank)

International bank account number: GB34MIDL40461031461656

Branch Identifier code: MIDLGB2162L, Sort code: 40-46-10

Account number: 31461656, Currency: British pounds Sterling

Bank Address: 122 Wembley Park Drive, Wembley Park, Middlesex HA9 8HT, UK

Bank Transfer to Vitality Living India

Current account name: Vitality Living

Bank Name: Canara Bank, Puttaparthi, Andhra Pradesh, 515134

Account number: 2351201000453

IFSC: CNRB 0002351