NAME                             

AGE                               

N.I.C. NO. (If exists)         

DATE OF WORKSHOP    

PLACE OF WORKSHOP  

QUALIFICATION             

PROFESSION                 

DESIGNATION                 

NAME OF COMPANY      

OFFICE ADDRESS          

RESIDENTIAL ADDRESS

CITY                               

ZIP CODE                       

COUNTRY                       

TEL (OFF) :                            TEL (RES) :

FAX          

E-MAIL ADDRESS           

HOW DID YOU COME TO KNOW ABOUT THIS COURSE:

(Check all that applies)

   NEWS PAPER       MAIL        FRIEND

   WEBSITE               SEARCH ENGINE

Others :

HAVE YOU HAD ANY EXPERIENCE IN MEDITATION:

(SILVA / NLP / AVTAR / RM / QUANTUM / C.M.  ETC...)

ARE YOU TAKING ANY MEDICATIONS FOR STRESS, TENSION, DEPRESSION, OR ANY OTHER PSYCHOLOGICAL AILMENTS ?

TERMS & CONDITIONS:

After filling the above from, you do hereby confirm that You have joined THE FOURTH DIMENSION Workhop entirely on your own responsibility and you will not hold any individual, teacher, group or the Institute of Mind Sciences, Pakistan responsible for any ill effect or medical problem.

You agree to use the techniques and exercises taught in the above workshop for the betterment of yourself and humanity in general.  You will not use the techniques to hurt or harm any living being and may God help and guide you.

  Agree         Don't Agree

Please indicate the ares(s) you want to improve at this time.  You can indicate more than one area too.

  Self Esteem           Time Management   Good Memory

  Weight Control         Creativity           Sports Excellence

  Better Health          Relationships        Good Judgement

  Higher Income          Sleep & Dreams      Concentration

  Reduce Stress         Problem Solving      Self Awareness

  Decision making        Salesmanship       Change Habits

  Goal Setting          Higher Grades       Intution

  Speaking Ability        Productivity          Self Confidence

  Relieve Headaches / Pain                        Build Confidence

Others: