Please take a print out of this form and send it through post after
filling the detailed information.
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APPLICATION  FORM  FOR  LOVE  THERAPY

NAME : _____________________________________________

AGE : ___________  HEIGHT: __________ WEIGHT: ________

DATE OF BIRTH: __________ TIME OF BIRTH: ___________

BIRTH PLACE (City/Village/Country) ______________________

BLOOD GROUP _____________________________________

COUNTRY: _________________________________________

FOOD HABITS:
MORNING __________________________________________

NOON _____________________________________________

EVENING __________________________________________

NIGHT _____________________________________________

FAVOURITE COLOR _________________________________

FAVOURITE ODOUR ________________________________

FAVOURITE SEASON _______________________________

FAVOURITE TIME ()Morning ()Day ()Noon () Afternoon () Evening ()Night

FAVOURITE FLOWER _______________________________

FAVOURITE FRUIT __________________________________

FAVOURITE NUMBER (From 1 to 10) ___________________

FAVOURITE PLACE ()Mountain ()Ocean ()Plains ()Forest 

ADDICTED TO ()Tobacco ()Alcohol ()Narcotics ()Others _____

HOBBY ___________________________________________

WORKING HRS PER DAY ___________________________

SLEEPING HRS PER DAY ___________________________

RESTING HRS PER DAY ____________________________

YOUR PREFERENCE FOR TIME PASSING:
()To Be Alone ()To be with many people ()To be with preferred ones

YOUR EDUCATIONAL QUALIFICATION
__________________________________________________
__________________________________________________
__________________________________________________

YOUR OCCUPATION _______________________________

MARITIAL STATUS ________________________________

ANY PHYSICAL PROBLEMS
()Impotency ()Indigestion ()Cardiac Problems ()Asthama ()Diabetes ()Others

THE SPECIFIC PURPOSE FOR UNDERTAKING THIS LOVE THERAPY
__________________________________________________
__________________________________________________
__________________________________________________

FIELD OF PROBLEM
()Education () Profession ()Business ()Performing Arts 
()Competitive Examination

Declaration: I, __________________________________ hereby declare that
without any coercion or compulsion has agreed to go through the six months course 
of Love Therapy & for the purpose is applying for membership. I further declare that
all the above mentioned information are true best to my knowledge. I will in no case
deliver of show the course material I will get to anybody or insist anybody to go through 
it under my supervision.

I WILL CONTINUE THE PRESENT TREATMENT THAT I'M UNDERGOING 
BESIDES THE LOVE THERAPY.

__________________________
Signature                                                                        Date:

Please Note: This is just a therapy & in no case can substitute medical treatment. But, if 
you donot get any remarkable change within a year and if that can be establised by medical 
examination, L.O.V.E. will refund the whole course fee.