Phone or FAX your registration

To phone in your registration, please have the information requested below handy. To FAX your registration, please print this page, fill it out and FAX it to 267.295.9904

Name on Card:   ____________________________________

Card Type:
 
Visa MC Discover AMEX

Card Number: 		 
____________________________________

Expiry Month/Year: 		 
____/_____           Card Code________

The Card Code, is a 3-digit code located on the back of your credit card, on the signature strip just to the right of the card number. On American Express cards, the 4-digit code is on the front of the card, just above and to the right of the embossed card number. Some non-U.S. credit cards may not have this code.


Your Name:_____________________________________________
Day Phone:___________________ Home Phone:___________________
Fax:___________________ Email:___________________
Address:_____________________________________________
City:___________________ State/Province:_______________
Postal/Zip Code:_______________ Country:_______________

I am paying $297 to reserve my place. I understand the remainder is due at the registration table, just before the seminar begins.

I am paying $297 to reserve my place. I understand the remainder ($1200) is due in monthly installments of $100.

I am paying full tuition ($1497 [subtract any discounts if applicable]).

I am Male Female

I wish to have a roommate I do not wish to have a roommate

If you have a code, put it here: __________