New Student Questionnaire

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" rowspan="2" width=200 BGCOLOR="#000000" TEXT="#F7F7FF"> <div> <B><IMG SRC="1988ce20.gif" border=0 width="140" height="226" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> </td> <td valign="top" colspan=2 height=94 BGCOLOR="#000000" TEXT="#F7F7FF"> <div> <FONT SIZE="3" COLOR="#BF0000" FACE="Garamond" ><B>Goddess Touch</B><B>     |    </B></FONT><B> </B><A HREF="index.htm" TARGET="_top" TITLE="Goddess Touch"><U><B>home</B></U></A><B>    </B></div> <div> <A HREF="contact.htm" TARGET="_top" TITLE="Contact Information"><U><B>c</B></U></A><A HREF="contact.htm" TARGET="_top" TITLE="Contact Information"><U><B>ontact information</B></U></A></div> <div> </div> </td> </tr><tr> <td valign="top" height=386 colspan=2 BGCOLOR="#BF0000" TEXT="#F7F7FF"> <div> <B>New Student Questionnaire</B></div> <bR> <div> <I><B>I</B></I><I><B>f you are interested in a serious pursuit of Tantric Spiritual Practice, please complete the following form and submit to me.  By complying, you are agreeing that you are representing yourself accurately and truthfully.  The teachings and practices that we will engage in are ancient, secret and sacred.</B></I></div> <bR> <div> <I><B>I am not offering escort services nor services of prostitution. I reserve the right to decline appointments as I deem necessary. Anything else that may occur is a matter of personal choice between consenting adults of legal age and is not contracted for, nor is it requested to be contracted for, nor compensated for,  in any manner.</B></I></div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B> <form action="http://csbmail.globalscape.com/cgi-bin/csbmail/csbmail.pl" method="POST" enctype="application/x-www-form-urlencoded"><input type="hidden" name="tlx_SortOrder" value="Name,Email,City,State,Zip,Phone,Self-Description,previous Tantra Training,Any Physical or Sexual Problems?,3 goals to acheive from your training:,Fears or Concerns?"><input type="hidden" name="tlx_FormIndex" value="1"><input type="hidden" name="tlx_OKMessage" value="Thank You! for allowing me to be a part of your journey."><input type="hidden" name="tlx_SendMode" value="1"><input type="hidden" name="tlx_Subject" value="Student Questionnaire"><input type="hidden" name="tlx_EmailTo" value="shanti@goddesstouch.com"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">Name:<br> <input type="text" name="Name" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Email:<br> <input type="text" name="Email" size="30" maxlength="100"></td> </tr> <tr> <td align="left">City:<br> <input type="text" name="City" size="30" maxlength="100"></td> </tr> <tr> <td align="left">State:<br> <input type="text" name="State" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Zip:<br> <input type="text" name="Zip" size="10" maxlength="10"></td> </tr> <tr> <td align="left">Phone Number:<br> <input type="text" name="Phone" size="14" maxlength="14"></td> </tr> <tr> <td align="left">How would you describe yourself?:<br> <textarea name="Self-Description" rows="5" cols="30"></textarea></td> </tr> <tr> <td align="left">Previous Tantra Training:<br> <input type="text" name="previous Tantra Training" size="75" maxlength="900"></td> </tr> <tr> <td align="left">Any Physical or Sexual Issues?:<br> <input type="text" name="Any Physical or Sexual Problems?" size="75" maxlength="900"></td> </tr> <tr> <td align="left">3 Goals for Your Training:<br> <input type="text" name="3 goals to acheive from your training:" size="75" maxlength="900"></td> </tr> <tr> <td align="left">Any Fears or Concerns?:<br> <input type="text" name="Fears or Concerns?" size="75" maxlength="900"></td> </tr> <tr> <td align="right"><input type="reset"> <input type="submit" value="Send" name="tlx_send"></td> </tr> </table> </form>  </B></div> <bR> <bR> </td> </tr></table></body>