FU ZU BA School Student Massage Clinic Customer Registration Form 富足吧学生按摩客户注册表
阅读并打勾 Read and check
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Student massage clinic is performed by training students and supervised by instructors. Students shall not accept any compensation for this service. 学生按摩治疗是由在校学生在老师监督下提供的按摩服务. 学生不能为该服务收取任何报酬.
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Student massage trainees will be appointed to you by instructors. 学生按摩师由老师指定.
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All student massage clinic will be conducted at the classroom site. 所有学生按摩将在按摩教室进行.
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I understand that I may not be treated if I have contra-indications. You may consult with the supervising instructor if not sure. 我知道如果有禁忌症, 将不会被按摩. 如有疑问, 可以询问监督的老师.
Internal Use Only 内部使用,不需填写
Your payment is processed by authorized.net directly. We do not store your payment information.
Registration must be completed online by the customer along with an appropriate payment to be valid. 注册流程要求申请人在网上登记,同时完成信用卡或银行卡付费信息。
Payment Status
Appointment 预约时间
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Choose and pay 选择并付费
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Chair Massage 30-min
椅背按摩 30分钟
$
20.00
Swedish Massage one-hour
瑞典油压 一小时
$
30.00
Credit Card or Debit Card 信用卡或者银行卡信息
First Name 名
Last Name 姓
Credit Card Number 信用卡号码
Security Code 信用卡安全号 3-4位
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month 有效期月份
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
Expiration Year 有效期年份
Billing Address (must match the bank record) 信用卡或银行卡账单地址 (必须跟银行记录相符)
Street Address 地址
Street Address Line 2 地址(第二行)
City 城市
State / Province 州
Postal / Zip Code 邮编 5位数
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country 国家(Select the 1st one: USA; 选择第一个:美国)
Customer Name 客户名字
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First Name 名
Middle Name
Last Name 姓
Customer E-mail 电子邮箱
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Mobile Number 手机号
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Additional Comments 特殊要求
Signature 签字
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Human verification 人机认证
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Submit Application 提交申请
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