THIS IS NOT AN ONLINE REGISTRATION FORM - FOR PRINT ONLY            Printed Date: 10/16/2019 12:28:02 AM

Seminar Title:
Mindfulness Certificate Course: 2-Day Intensive Training
Seminar Date:
Thursday, October 10, 2019
Seminar Location:
PITTSBURGH, PA 15241
Seminar ID:
73843

  Required (select one)
 
$499.99 Single Registration
$439.99 2+ Group Rate: per person
$429.99 5+ Group Rate: per person
$250.00 Student
  ________ HI, NM attendees add applicable sales and local taxes**
  ________ Subtotal (Required items + sales tax)
 
  Magazine Subscription
 
$12.99 Psychotherapy Networker Magazine Subscription - 1 Year (Full Price $36.00)
 
  Optional
 
$29.99 Cognitive Behavioral Therapy & Mindfulness Toolbox:50 Tips, Tools and Handouts for Anxiety, Stress, Depression, Personality and Mood Disorders
$19.99 Mindful Living Card Deck: 56 Practices to Feel Calm, Balanced, Happy & Present
$16.99 Growing Mindful 2nd Edition: Mindfulness Practices for All Ages 58 Card Deck
$15.00 Reflect: Awaken to the Wisdom of the Here and Now
  ________ AL, AR, AZ, CA, CO, CT, DC, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, NC, ND, NE, NJ,
NM, NV, NY, OH, OK, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY attendees add applicable sales and local taxes**
  ________ Subtotal (Magazines + Optional items + sales tax)
   
  ________ Total (Required subtotal + Optional subtotal)
  ** Tax-exempt customers please send a copy of your tax-exempt certificate.
  *** Registration for coordinator or military member discount must be completed online
  **** All prices are shown in US Dollars ****
 
 

Please enter the MAIL CODE in the box below.

If you have a brochure, this code is found on the
back in the box above the address block.

If you do not have a brochure, please enter 888.

Mailcode Example
Mail Code or VIP #:
*  
First Name:
*     Last Name: *
Profession:
*
  Note: Leave Company/Department blank if providing home address
Company Name:
*
Department:
*
Address:
*
City:
*    State: *    Zip: *    County: *
Work Phone:
*      Cell Phone:   *      Fax Number:  
Email Address:
*    License Number: *
(required for confirmation of registration)

  Prepayment is REQUIRED
  Check enclosed
  Signed Purchase Order enclosed
Credit Card Type:
Mastercard    Visa    Amex    Discover
Credit Card #:
  V-Code #*
Exp Date:
/ *MC/Visa/Discover: last 3-digit # on signature panel on back of card
*American Express: 4-digit # above account # on face of card
Name on Card:
Mail or Fax to:
PESI, P.O. Box 1000, Eau Claire, WI 54702-1000      (800) 554-9775 (fax number)