AMOU

ANOTRA / The ANOTRA form

The ANOTRA form

Your Information:

Title

First Name

Last Name

Date of Birth


Year	Month	Day

Gender

Male

Female

Your city & country of Birth

Father's country of Birth

Mother's country of Birth

Are you acquiring this for yourself or another party?

For myself

For another person

COMPLETE ONLY WITH THE OTHER PERSON INFORMATION
(Not your information)

Relationship of the other person to you

Gender

Male

Female

Date of Birth


Year	Month	Day

Complete only if you know the information. Leave blank the part that is not know

For the other person: city & country of Birth

(Leave blank if not known)

For the other person: Father's country of Birth

(Leave blank if not known)

For the other person: Mother's country of Birth

(Leave blank if not known)

Please indicate your primary desire for ANOTRA

Choose one

	Protection against ills and diseases
	Maintain Health
	Healing from ills and diseases
	Vitality

In about 200 words or less, please write why you are requesting the ANOTRA Kajou

You must be at least 18 years of age before you use this service