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Fourth Way Workshop Registration Application 2004

INSTRUCTIONS:
Please save this Application to your computer or email program,
complete it in full, and send the completed application via email to
fourthwayworkshop@yahoo.com.

If an item does not apply to you, please write N/A or Not Applicable.
Incomplete applications cannot be considered.

REGISTRATION DEADLINES:

To Be Determined.


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Today's Date:

Date and Location of Workshop (Choose one):

To Be Determined.

Title:

Last Name, First Name:

Gender:

Any other names you use or have used:

Email:

WWW URL:

Street Address:

City:

County, State, or Province:

Postal/Zip Code:

Country:

Home Telephone:

Work or Message Telephone:

Year, Date, Time, and Place of Birth:

Nationality now, and any others you hold or have held:

Marital Status:

Any Children?:

Occupation, profession, or trade:

Education, Qualifications, Degrees:

Hobbies, Interests, Special Skills or Talents:

Details of any Criminal Charges or Convictions:

Details of any mental instability or illness:

Details of any chronic physical illness:

Details of any alcohol or substance usage:

Details of any exposure to, or infection with, contagious diseases:

Details of any self-development, self-cultivation, martial arts, or cult groups
of which you are now, or ever have been, a member; details of group name,
membership dates, your personal activities within the group, and details of why
you left the group:



What are your reasons for wanting to attend this workshop? What do you want to
accomplish?:


On a scale of 1 to 10 (with 1 being least familiar and 10 being most familiar),
how would you rate your experience and understanding of the work ideas and
practices?


By submitting this application you swear and certify that all the information
is true and complete to the best of your knowledge and that you are prepared to
substantiate all particulars; that you understand that any incomplete or false
information will result in immediate dismissal with no recourse whatsoever,
legal or otherwise, and you waive all rights to legal actions; that you are
acting entirely on your own behalf and not as an agent or representative either
express or implied of any group, organisation, or entity; and that you will
keep confidential and private all information you become privy to and will not
reveal such information to anyone except as required by law.

Property of and © Copyright 2003 Fourth Way Workshop. All Rights Reserved.
Fourth Way® is a registered mark.
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