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MAGITEQUE COHORT REGISTRATION FORM
I would like to become a Magiteque WellBeing Cohort:
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I enroll under Magiteque Well-Being Cohort Category of:
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Self Care
Patient / Care Giver or Member of the Family of the Patient
Well-Being Center Enterprise
Volunteer Disaster Responder
Professional Health Care Provider
I understand that there are qualifications and criteria I need to meet to be accepted in different Magiteque Well-Being Cohort Program and I cannot question the decision of the Magiteque Management if I do not qualify, but I can always make an appeal for consideration.
PERSONAL INFORMATION
Name
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First
Last
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Email
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Phone Number
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Address
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Line 1
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City
State
Zip Code
Country
Sex
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Birthday
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Weight
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Civil Status
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Age
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Height
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EDUCATIONAL BACKGROUND
Highest Education Attainment
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Elementary Graduate
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College Graduate
Doctorate Degree
Highest Education Attainment Document Support:
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Max file size: 20MB
WORK EXPERIENCE
Current Engagement
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Currently Employed
Owned a Business
No Well-Being related work
Upload Supporting Documents applicable to work experience.
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Why would you like to become a Magiteque Well-Being Cohort?
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Submit your Best Full Body Picture
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Upload File of your 2x2 ID Picture
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Upload Any Government ID
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