Registration form  2009

 

Name ____________________________ Address __________________________

 

City _____________________________ State _____________ Zip ____________

 

Phone  H _________________________ Phone  W _________________________

 

Phone C__________________________ Email  ____________________________

 

*      $100 Workshop Fee

*      $15 CE Processing fee.

 

Lic: # ________________________

 

Check # ________ Payable to Rev. Tracy L. Parker

 

  Visa     Mastercard

________________ญญญ____  ____________

Credit Card Number         Expiration Date

 

Please mail completed form, payment to:

Rev. Tracy L. Parker

55 N. Auburn Suite D

Sierra Madre, CA. 91024

Refund Policy: 90% up to one week before class.