Mokshya E-commerce website

Student Enrollent Application Form

New Student Enrollment

Please complete and submit the form below to register. Let us know if you have any questions. Contact us at 01-5536209 or contactmokshya@gmail.com

Student Enrolment

Name*

Address*

Gender*

Age*

Marital status*

Education*

Profession*

Contact number*

Email*

Emergency contact person*

Emergency contact number*

Services you choose*

Courses you want to enroll*

Diseases*

High Blood Pressure Low Blood Pressure Depression Anxiety Asthma Arthritis Sugar Migraine Cholesterol/Heart disease

Any long-term disease/ Hereditary disease:

Sleeping hour and pattern*

Food habit*

Vegetarian Non-Veg Alcohol Smoking

Are you in any medication?

Clinical

Recreational

Currently are you engaged in any

Activities*

Others

How did you know about Mokshya?

Platforms*

Others

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Contact

Head Office & Studio

Kantinagar Tole, Dholahiti, Lalitpur, Nepal

01-5536209, 9803841931

contactmokshya@gmail.com

Showroom and Outlet

Amritmarg, Thamel

01-None