Registration Form

LK AYURVEDA RESEARCH TRAINING ACADEMY (M) SDN BHD Company No: 1082554-W
No. 11 & 12 Tingkat Atas, Taman Pundut Raya, Jalan Lumut, 32200 Lumut, Perak
Tel / Fax: 05-683 8162 H/P: 016-246 5474
email: lkacademy16@gmail.com website: www.munu2u.com
REGISTRATION FORM
(Malaysian Student)

Full Name (as in IC) : *

Identity Card No : *

Place of issued :

Citizenship/ Nationality : *

Race : *

Religion : *

Date of Birth : *

Country : *

Sex: *

Marital Status *

Mobile Phone : *

Email *

Postal Address: *

Permanent Address : *

Name of Father / Guardian : *

Identity Card No : *

Monthly Income : *

Citizenship / Nationality : *

Mobile Phone : *

Occupation :

Address : *

School / University *

Last Qualification *

From (year) *

To (Year) *

Job Title *

Organization *

Start Date *

End Date *

COURSE APPLIED FOR *

FINANCIAL *

Message

Contacts

LK Ayurveda Research Training Centre & Pusat Rawatan Naturopati
No 20, Batu 3, Pundut,
Jalan Lumut,
32200 Lumut
Perak.
Tel : 05-6838162
WhatsApp : 016-246 5474