|
|
| Simply
print this page, fill in the requested information, fax the form to: (818) 362-3181, or
mail-in the form. |
| Personal
Information |
| Name:_____________________________________________ |
| Address:___________________________________________ |
| City:____________________
State:______ Zip:__________ |
| Telephone
Number: _______________________ |
| Fax
Number: _________________________ |
| Email
Address: ________________________________ |
| Class
Information |
| Name
of Class: _____________________________________ |
| Date
of Class: __________________ |
| Class
Location: _____________________________________ |
| Payment
Information |
| MasterCard, Visa,
or Discover |
|
Card
Number: ______________________________________
Last 3 digits on
back of card _____________ |
| Exp.
Date: _________ |
Amount
Charged $_______________ |
I
authorize Consultants Extraordinaire to charge my card for
this class.
Signature: _________________________________________ |
|
The
charge will posted on your monthly statement as: Consultants Extraordinaire |
| Mailing
Address for Checks |
Consultants
Extraordinaire
12501 Rajah St.
Sylmar, CA 91342 |
