www.herbforhair.com

CHOR NATURE Co., Ltd.
1/32 Boromarajajonani Rd., (between Soi.5-7) , Arun Ammarin, Bangkok Noi, Bangkok 10700
Tel: 0-2434-8895-6 / Fax: 0-2884-6741 Mobile: 081-6289102
email: herbforhair@hotmail.com
[Click to see map]

Member Application

*Mr./Mrs./Miss		Age
Address : Home
*Tel.		Mobile
Fax
* E-mail
Office
Tel.		Fax
E-mail
*Enquiry :

Contact place	Home	Office
Mailing address	Home	Office
How do you get to know us ?
Hair Information
1. Your hair	short hair	long hair
2. Size/color	thick & shiny	thin light color or gray
3. Your favorite hair style	puffy	tidy
4. Your scalp	dry	oily
5. Shampooing
5.1 Shampoo	every day	every other day	times/week
5.1 Shampoo

5.2 Brand of shampoo used
5.3 Conditioner using	No	Yes	Brand
6. Chemical Treatment	No	Yes, have been through irritant chemical such as dry, curl or chlorine

Hair Problems

	Baldnes
	1.		Your hair is falling more than 50 hair per day.
	2.		Thin hair but not falling now.

Minoxidil / Finasteride Using

	never use or stopped more than 6 months
	still using
	stopped less than 6 months = months. You may have hair loss in these 6 months after stop using.

Gray Hair		Dandruff	Itching	hair Damage	Unhealthy hair
Do you have one or more of the following symptoms?
	Acne, red spot or skin rashes on face, eyelid, or scalp
	Itching on scalp, face, eyelid, eyelashes, or external ear channel especially at night.
	Hair loss of eyelashes or hair

	Date

1. Shop at the following distributors:

Bangkok

Distributor name	Address	Tel.
JIVA Hair and Scalp Complete Treatment Center	SUKHUMVIT branch 159/3 Soi Thonglor (between soi thonglor 7-9) Sukhumvit 55 Rd., Klongtun-nua, Wattana, Bangkok 10110, Thailand	0-2381-1057-9
PHYATHAI 1 Hospital	Building 1 (Herb corner near the reception) 364 Sriayudhya Rd., Rajdevi, Bangkok 10400	0-2245-2620 # 2194
KHUN SARAWAN (KHUN BOOM)	Siam Sicon Squre, 2nd Floor, Robinson zone, in front of stage show	0-9799-7704
Especially Shop	near SIRISAJ Hospital 274 Arun amarin Rd., Bangkok Noi, Bangkok 10700	0-2412-0551
Especially Shop	Klong-sarn Branch Open Monday-Friday 07.30-20.00 hours and Open Saturday-Sunday 10.00-20.30 hours
SAE-SOO	Bon Marche Boot 75-80 Prachanives 1, Ladyao, Jatujak, Bangkok	0-2954-3612
MOBILE SHOP	Ms. Pinyada	0-9499-5641, 0-2245-6900
PANAN CHAO-OEY	1262/1 Rama 4 Rd., Klongtoey Bangkok 10110	02-671-0131
Double A (Super service)	337 Taksin Rd. Klong-sarn, Klong-sarn, Bangkok 10600	0-2863-2510 084-7518172
K.S Pharmacy	near Robison Soi. Sukhumwit 17 Sukhumwit Rd., N.Klongtuay Bangkok 10110	0-2225-21916 Fax.0-2252-8845
Safe & Save Pharmacy	Big C Akekamai Soi.6 2nd floor opposite Index Living Mall Akekamai Power Center Building Soi.Sukhumwit 63 N.Prakhanong Wattana Bangkok 10110	0-2714-8267 Fax.0-2714-8266
Safe & Save Pharmacy	opposite Seri Center Mall 168 Thanon Srinagarindra KWANG NONGBON, KHET PRAVES, BANGKOK 10250	0-2383-8645-6 Fax.0-2383-8855
Tongyang Co.,Ltd (China Town)	618 Charoen Krung Rd., Khet Samphanthawong, BANGKOK	0-2221-7682, 0-2225-9134
Tongyang Co.,Ltd	Faculty of Architecture Chulalongkorn University	089-667-9274
Tongyang Co.,Ltd	Faculty of Architecture Thammasat University	089-780-3613
Future Mart	Home Pro Rama 3 Herb Shop Front Casher in Max Value Supermarket	084-679-3949
Fashion Island	Second floor “Member Cut” near Bangkok Bank	0-2947-6055, 081-774-7145
Salon in Soi Prajane	Vitayu Road	0-2251-8008, 086-751-4799
BTS Chong Nonsi	Exit 4 Tune Right (K.Voravate Tianjaroenchai)	087-992-3800
Bhum Jai Thai	Branch Central Ladprao G Ground	087-5706643
Bhum Jai Thai	Branch I Place Ladkrabang	087-035-8837
Bhum Jai Thai	Branch Lotus Bangkae G Ground	087-5706643
Vicha Salon	16/56 Charan Sanit Wong 13	085-058-9118
Wanvisa Maitai	Carrefour Rama IV 3rd floor	02-6412604
PINIJNUUN CLINIC	Soi.Prachasongkroa 23, Next to Bangkok Bang, Behind HOKARNKA UNIVERSITY	02-277-8408
MHORYAMAHADTHAI DRUG STORE	214, 216 Chaikarnplace 2 Soi. Lardprao 122(Soi.Mahardthai) Lardprao ST. Wangtonglang Bangkok 10310	02-542-2359, 087-099-1319
YADEE DRUG STORE	21/4 Ramintra 58 Soi. Punjamit Kannayao Bangkok 10230	02-947-9393, 081-583-8987
Phannarai Beauty and Spa	Future Park Rangsit, 1st Floor	0-2958-0312
Pho Thong	beside Lung Phoem market, behind the head office of Thai Airways, Vibhavadi Rangsit Road (Khun Keng)	089-201-0418

Province

Distributor name	Address	Tel.
Jiramanee Beauty Spa and salon	123 M7 Pahonlayotin Street Chiangraknoi Bangpain Ayuthaya 13180 (K.Voravate)	087-992-3800
Klongdinsor Shop	9/13 Moo.4 Sano Amphoe Bang Bua Thong Nonthaburi 11110	0-2571-1931
Siam Products Shop	Front Red Cross 141/6 Rajbhakinai Rd., Sripum,Muang, ChiangMai	053-225-477, 053-213-837
V Shop HORKOI Branch (KHUN NISANART)	170/1 Nangpim Rd., Ta Pee Liang, Muang, Suphanburi 72000	035-525369
Healthy Shop (KHUN TANAWAT)	814/171 Norrasing Rd., Mahachai, Muang, Samutsakorn 74000	086-319-4950
Ran Samunpai Matum Mahemiyw	(K.Surag) 97/86 (Behind Assumption College Sriracha) surasak Sriracha, Chonburi 20110	081-923-0615
BoonChan Pharmacy	68/13 NIKOM AMATA NAKORN Donhonlor, Chonburi 20000	038-454-783
La ca sita	99/304 M.8Classic home raikuay Rd. surasak sairachar chonburi 20110 (K.Voravate)	087-992-3800
SU-SHIVA SHOP	81/39 Prayasajja Rd., Muang, Chonburi 20000 (near NAMDEE Duck Noodle Shop)	038-286-596
B MART KOSUM BUILDING	614 Moo. 15 Jamjuree ST. Bohaew Lumpang 52100	081-951-9290, 081-803-2957
Beauty Salon	67 Akhan Songkhro Road, Sateng, Mueang Yala, Yala 95000 (Khun Natcha)	073-221-273
Cheewit Chitchai	194 Prachak Road, Mueang Nakhon Ratchasima, Nakhon Ratchasima, 30000, near Pratu Phonlasen Crossroad, www.mind-bodykorat.blogspot.com	044-247537, 086-6538752
Chayakorn Digital Lab	opposite the city municipal (old),7, Phiphit Prasat Road, Phra Prathom Chedi, Mueang Nakhon Pathom, Nakhon Pathom 73000	034-242-677 (8.00 AM– 8.00 PM)

2. Shop directly at

JIVA HAIR AND SCALP COMPLETE TREATMENT CENTER by CHOR NATURE 1/32 Boromarajajonani Rd., (between Soi.5-7) , Arun Ammarin, Bangkok Noi, Bangkok 10700 or order (free delivery) to 0-2434-8895-6 by cash transferring to saving account of “KANABOOKKON HERBFORHAIR” of any bank as the following :

Bank		Branch	Account Number
	Bangkok Bank	Phuddhamonthon	247-0-54655-3
	Kasikorn Bank	Oomnoy Sub Branch	439-2-41005-3
	Krungthai Bank	Oomnoy Branch	732-0-01714-8
	Bank of Ayudhaya	Oomnoy Sub Branch	337-1-59685-1
	Thai Military Bank	Oomnoy Branch	439-2-56941-6
	SCB Bank	Salaya Branch	316-2-51862-0

The products will be delivered by express mail or a messenger if in Bangkok .
N.B.	1. Buying more than 1,500 Baht in the first order or 100 Baht fee paym ent will get membership which can get 10% discount immediately.
	2. Members will get 10% discount when buying at shops at any amount of order except when the products are delivered by mail the minimum order for 10% discount is 600 Baht and 1,500 Baht if delivered by a messenger.