Shakti Kriya Form

Medical History
1. 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 History
Number 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 share
Single
USD 400
USD 600
WE HAVE 2 OPTION OF BANK (wire)TRANSFER :
Beneciary Bank and Address :
BANK OF INDIA,
SINGAPORE BRANCH, SINGAPORE
SWIFT CODE :
BKIDSGSG

Beneciary Name :
YAYASAN SENI KEHIDUPAN / ART OF LIVING
Beneciary Account Number :
(USD) 5359300102
Beneciary Bank and Address :
Bank MEGA ,
Branch Hasanudin, Jakarta Selatan,
Indonesia
SWIFT CODE :
MEGAIDJA

Beneciary Name :
PT Sri Sri Yoga
Beneciary 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 email
2. Pay in FULL AMOUNT
3. Scan the Registration & Accomodation form and TT (bank transfer receipt)
copy and email it to info@artofliving.or.id
4. 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)