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REGISTRATION FORM
REGISTRATION FORM
Print this form, then fill in the requested information and mail or fax it to us. You may also call Zenith at (281) 996-9109 Monday-Saturday after six p.m. Central time to register.
TO FAX: (281) 993-0792
DO NOT E-MAIL CREDIT CARD INFORMATION
I have enclosed a CHECK or MONEY ORDER for $450.00 IN FULL PAYMENT OR $100.00 Deposit (Non-Refundable) to reserve my seat in the class for the indicated course...
BASIC____INTERMEDIATE____ADVANCED____
Please charge my credit card:
Zenith accepts all credit cards please write in the card name you wish to use. __________________________________________.
Account #_____________________________ Expiration Date ________.
Name on credit card _________________________________________.
Amount to charge card $100.00 or $450.00
If your card has a security code (Three numbers on back) please include them here ________________________.
STUDENT'S NAME ____________________________________________
ADDRESS ___________________________________________________
CITY __________________________ STATE __________ ZIP ________
PHONE: (DAY) ________________________ (EVENING) _______________
FAX: _________________________ E-MAIL (OPTIONAL) ______________
@_________________________.
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Basic Hypnosis
Intermediate/Advanced Hypnosis
Send E-Mail to: lhaymon@houston.rr.com or
Copyright © 2003 Lloyd L. Haymon. All Rights Reserved