• Please provide the following contact information:

  Title	Dr., Mr., Mrs.
  First Name
  Middle Initial
  Last Name
  Profession	D.C., N.M.D., Reiki, ETC.
  Company
  Street Address
  Address (cont.)
  City
  State/Province
  Zip/Postal Code
  Country
  Work Phone
  Home Phone
  FAX
  E-mail
  Web Page
  Who Referred You

• Please state which Seminar you would like to Register for

  Seminar	Date

  	BILLING
  Credit Card	Visa or Master Card only
  Expiration Date	Code on back of card
  Amount	US Euro Currency

We appreciate your advanced planning.

Winners make commitments, losers make excuses.