| Name: |
| Mailing Address: |
| City: |
| Home Phone: |
| Work Phone: |
| Cell Phone: |
| Email: |
| Credit Card Type: |
| Courses (please select one): |
| Comments: |
| Once your credit card payment has been confirmed, you will receive a confirmation email in 2-3 business days that includes both a receipt and your e-course materials. No refunds can be given once course materials have been emailed. |
| Credit Card Number: |
| CV Number: |
| City: |
| Billing Address: |
| Name on Card: |
| State: |
| Zip Code: |
| State: |
| Zip Code: |
| **please note** You must register for each class separately. |
| Please complete all boxes. You must complete a separate form for each course selected. When you click on the submit button, your credit card will be charged $20 per course, plus 7% sales tax, for a total of $21.40 (*with the exception of courses CDA1 & CDA2, which are $10 + .70 tax for a total of $10.70). If you have a coupon, please put the coupon code in the comments box below. You will receive a confirmation email with your course materials in 2-3 business days. |
| Please Note: You MUST click on the TOP of each box in order to type in information. |
| Expiration Date: |
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