REIKI TUMMO DISTANT LEARNING STUDENT DATA

(FOR ALUMNI DATA AND CERTIFICATE)

(Please complete this form and then email back to us along with your paypal payment receipt. You can copy and
paste this data into your email instead of using email attachment. Your personal information will be kept
confidential. However, you may leave some lines blank if you wish).

1. First name: ______________________________ 2. Midle name: ________________________________

3. Last name: ______________________________ 4. Gender: ____________________ (Male or Female)

5. Place and Date of Birth:

____________________________________________________________________
6. Name and title you wish it to appear on your certificate:
____________________________________________________________________
7. Home Address:
____________________________________________________________________
8. Complete Postal or Mailing address to send the certificate (include: City, Province, State, Country and Postal
Code or PO Box Number):
. ____________________________________________________________________

9. E-mail Address: ________________________ 10. Web Site Address (if any): ________________________

11. Skype ID (for online guidance/exercise): ______________________________

12. Home Phone number <country code> + <area code> + <Phone number>:
______________________________
13. Mobile Phone number <country code> + <area code> + <Phone number>:
______________________________
14. Fax Number <country code> + <area code> + <Phone number>:
______________________________

15. Distant Learning Package: (please choose one and delete the rest):

1 or 2 or 1&2

16. Amount of Payment: US$___________ 17. Payment method: ______________ (e.g. PayPal or via friend)

18. Date of Payment: ____________________

19. Your Local Time Setting Name (e.g. PDT, EST): ____________________

20. Your Local Time Difference to GMT Time (e.g. GMT – 12 hours, GMT + 7 hours ): ____________________
(please visit http://www.timeanddate.com/ for guidance)
21. Proposed Distant Attunement Schedule for Each Level (day, date and your local time):
Level 1: ______________________________
Level 2: ______________________________ (at least 1 day after Level 1 attunement)

22. Proposed your available time for Skype online guidance/exercise (1-2 hours time):
___________________________________________________

NOTE:
a) The 2nd level attunement should be done at least one day after receiving the 1st level attunement. Please propose
your most convenient schedule and you need at least 1 hour quality time for each level of attunement (15 minutes
attunement + 45 minutes self healing practice right away after the attunement). Do not worry about our local time
difference. We can easily adapt to your proposed schedule.
b) If you are in USA, Canada, Europe or New Zealand, please email this data along with your PayPal payment
receipt to reikitummo@gmail.com and please add the Skype ID of paramajaya to your Skype contact list. If you
are in Asia or South America or other country please email to tettyj@gmail.com and add the Skype ID of tetty05 to
you Skype contact list.

c) If you have a facebook account, before or after the attunement, you are welcome to join our facebook discussion
groups: https://www.facebook.com/groups/Kundalini.Reiki.Tummo/ for discussion in English
or https://www.facebook.com/groups/Reiki.Kundalini.Bukahati/ if you understand Indonesian. We have active
sharing and discussions amongst our alumni all over the world. Please add also the facebook account of Reiki
Tummo as your facebook friend to ease the subscription to those facebook groups.