EMPEROR PHYSICAL FITNESS CENTRE 帝 王 保 健 中 心

Registration office: c/o: Goldwall Sdn Bhd Lot 25-2-23, 2^nd Floor Plaza Prima, Old Klang Road, 58200 Kuala Lumpur

Tel: 03-781 9317 Fax: 03-780 8185 E-mail: ekungfu@yahoo.com Homepage: www.oocities.org/ekungfu

Important notice: You are to disclose in this registration form and any other questionnaires fully and faithfully all facts which you know or ought to know.

To achieve best result, appropriate and specific training besides standard training will be provided according to the needs of applicant.

All materials in this registration form shall be treated highly private and confidential.

登 記 表 格

Registration Form

帝 王 龍 珠 洗 髓 功 訓 練 課 程

For learning of THE EMPEROR DRAGON BALL KUNG FU COURSE

Date 日 期:___________________

Full Name 姓 名				Chinese Name 中 文 姓 名
I.C. No. 身 分 證 號 碼			Date of birth / 出 生 日 期
Correspondence address 通 訊 地 址:
Telephone number: 電 話 號 碼 ：	Hand phone / 手 提	Office / 辦 公 室			Home / 住宅
Commencement Date 開 課 日 期 ： To 至 (End 終 )
Weight - kg.:		Height - cm:

Further particulars of applicant. Please tick Yes or No ( if yes please give full details) Have you ever suffer or receive any of the followings? 閣 下 有 無 以 下 病 痛 或 症狀, 如 有 請 勾 yes.
No.	Description描述	Yes	No	No.	Description描述	Yes	No
1	Hypertension 高血壓			11	Insomnia失眠症
2	Diabetes糖尿病			12	Rheumatism風濕病
3	Arthritis關節炎			13	Swollen prostate前列腺腫大
4	Fatigue 易疲勞			14	Malfunctioning of liver肝臟 功 能 差
5	Frequent discharge of urine 頻 尿			15	Pain in hips and back 腰 酸 背 痛
6	Impotent陽萎			16	Unsuccessful copulation 中 途 倒 陽
7	Small pennies短 小			17	Bodily / Stomach weak 體 虛 胃 寒
8	Unstiff erection 不 堅			18	Coldness of limbs 手 足 冰冷
9	Sinus竇炎			19	Problem in sex 性 生 理 苦
10	Early ejaculation 早 洩			20	Weak in memory 記 憶 減 退

Important declaration by applicant: Applicant must be:- 申請者重 要申報, 余

1. Free from any venereal diseases 沒 帶 任 何 性 病 病 菌
2. No record of major internal organ surgery 沒 動 過 內 臟 大 手 術

余 ， 鄭 重 申 明 以 上 問 答 皆 是 正确的, 決 無隱瞞 任 何 實 事 I, declare that the above answers are full and true, that I have not withheld any relevant information.

申 請 者 簽 名 Signature of applicant

For office use only: 供 公 司 用

Date received:		Received by:
Deposit paid	RM	Referred by:
Paid by cash / Cheque no:		Receipt no.
Balance to be paid. RM		Instructor:
DEPOSIT OF RM 1,000.00 WITH THIS FORM MUST REACH THE OFFICE 2 WEEKS BEFORE CLASS COMMERCE		Signature

Emperorform *Terms and conditions overleaf applied. 其 他條件 請閱讀背面