Name :
Age
& Date of Birth :
Postal
Address :
Telephone :
email
address :
*I
would like to join the Acupressure Club as a Member and avail the free
acupuncture treatment consultation for one year Registration Fee of Rs. 1000/- (Rupees one thousand only)is enclosed by Cash / Cheque / Draft drawn in favour of
Mrs. Meera Bhojraj.
*I
would like to subscribe only for the Acupressure Newsletter (and do not
want to avail any free treatment) subscription fee of Rs. 250/-
(Rupess two hunderd fifty only) is enclosed by Cash/ Cheque/Draft drawn
in favour of Mrs. Meera Bhojraj.
Date:
Signature
-------------------------------------------------------------------------------------------------------------------------------------------------------
Local
cheques or Demand Drafts payable at Bangalore should be sent to Mr. Palyam
Suresh 598, 11th Main, 5th Block, Jayanagar Bangalore
- 560
041.
------------------------------------------------------------------------------------------------------------------------------------------------------- Mr.
Palyam Suresh
Send this
form to our Programme Coordinator