GREAT SEMINARS AND BOOKS REGISTRATION
Please print, fill out the registration form, and fax or mail to:

Make all checks payable to: GREAT Seminars and Books, Inc.

NAME:                                                                                                                 

PROFESSION: PT PTA OT COTA (Please circle one)

EMAIL ADDRESS:                                                                                             

HOME ADDRESS:                                                                                              

CITY:                                         STATE:           ZIP:            

HOME PHONE:                                                           

EMPLOYER/OFFICE:                                                                                         

BUSINESS PHONE:                                                           

COURSE YOU WILL BE ATTENDING:                                                            

                                                                                                                                  

LOCATION OF COURSE:                                                                                    

DATES OF COURSE:                                                           

CREDIT CARD NUMBER:                                                             EXP DATE (MO/YR):                  

CARDHOLDER’S NAME (as it appears on credit card):                                                            

CARDHOLDER’S BILLING ADDRESS
(Street address, city/state, and zip code):________________________________________________

CHECK NUMBER:                                                           

Cancellation Policy: Cancellations must be received in writing at least two weeks prior to the seminar date for a tuition refund less a $75 administration fee. No refunds will be made after this date.

Note: Registrations made within 3 weeks of the date of the seminar will incur a $50 late fee.