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MAGITEQUE COHORT REGISTRATION FORM
I would like to become a Magiteque WellBeing Cohort:
*
Indicates required field
I enroll under Magiteque Well-Being Cohort Category of:
*
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
*
First
Last
Please fill-up with your complete name.
Email
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Sex
*
Birthday
*
Weight
*
Civil Status
*
Age
*
Height
*
EDUCATIONAL BACKGROUND
Highest Education Attainment
*
Elementary Graduate
High School Graduate
Vocational School Graduate
College Graduate
Doctorate Degree
Highest Education Attainment Document Support:
*
Max file size: 20MB
WORK EXPERIENCE
Current Engagement
*
Currently Employed
Owned a Business
No Well-Being related work
Upload Supporting Documents applicable to work experience.
*
Max file size: 20MB
Why would you like to become a Magiteque Well-Being Cohort?
*
Submit your Best Full Body Picture
*
Max file size: 20MB
Upload File of your 2x2 ID Picture
*
Max file size: 20MB
Upload your PRC / CNP / PITAHC ID / OTHER PROF ID
*
Max file size: 20MB
Referred By:
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