Seminar Registration                                   

Name ___________________________________________________________________________

Address ____________________________________________________________________________

Telephone Home ___________________ Work ________________ Cell _________________

Email _______________________

     ADVANCED REGISTRATION

Name of Seminar      _____________________________________

Date of Seminar Requested  _________________________________                                         

____ Check payable to Center For Mind Body Therapy _______________________________

____ Credit Cards: Charge my credit card - Master/Visa – as follows: _______________

Card Number _____________________ Exp. Date ___________

____Partial Payment Credit Card Option, $330 Registration, $300 at workshop, $300

one month later ($30 Administrative fee)

Authorization signature ________________________________