STUDENT’S NAME:______________________________________________________________

ADDRESS:_____________________________________________________________________

City:_______________________________________ POSTAL CODE:___________________

PHONE :____________________________ FAX :____________________________________

E-MAIL:______________________________________________________________________

What would you like to gain from this weekend:_______________________________

_____________________________________________________________________________

Please circle appropriate course/s

Basic Pranic Healing, and/or Advanced Pranic Healing, and/or Pranic Psychotherapy, and or Psychic Self-Defense, and/or Pranic Crystal Healing,

City and Dates of Class attending_______________________-____________________

Course Fee: ________________________________________________________________

$50 Deposit per course yes___________

Paid by cash $___________ amount paid $___________

Paid by cheque (payable to O& G Evolution Inc.) _________amount paid $______

Amount still owing: $_____________________

CREDIT CARD INFORMATION

VISA/MASTER CARD NO. ________________________________________________________

DATE OF EXPIRY ______________________________________________________________

NAME ON THE CARD ____________________________________________________________

SIGNATURE ___________________________________________________________________

Mail to: Jyoti S. Dekate
Bodhi Well-Being & Healing Center
Suite #508-4600 Crowchild Trail NW
Northland Professional Center
Calgary, AB, T3A2L6

Note: Payment Plan available.