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7. APPLICATION FOR FREE COPY OF
THE FLOW SYSTEM THERAPY WORKBOOK


I, A MEMBER OF MY LOCAL HEALTH ORGANIZATION, WOULD LIKE TO RECEIVE A FREE COPY OF THE FLOW SYSTEM THERAPY HANDBOOK TO THE BENEFIT OF MY COMMUNITY.

Please provide the following information:

First Name
Last Name
Title
Organization
Street address
Address (cont.)
Village/City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail
Organization URL

Please identify and describe yourself:

Education
Date of birth
Nationality
Sex Male Female

Please, describe your work in your organization and how it is related to the health care of your local community.

        


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2000 Copyright by Han M. Stiekema, M. D.
Last revised: February 14, 2005