THIS IS NOT AN ONLINE REGISTRATION FORM - FOR PRINT ONLY
Printed Date: 4/20/2024 5:55:02 AM
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Seminar Title: |
5-Day Certification Retreat: Nutritional and Integrative Medicine for Mental Health Professionals |
Seminar Date: |
Monday, May 10, 2021 |
Seminar Location: |
SEDONA, AZ 86336 |
Seminar ID: |
76497 |
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Required (select one) |
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EARLY BIRD REGISTRATIONS AVAILABLE THROUGH FEBRUARY 26, 2021
Single Occupancy
$1,899.00 By February 26, 2021
$2,099.00 After February 26, 2021
Double Occupancy
$1,699.00 By February 26, 2021
$1,899.00 After February 26, 2021
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________ HI, NM attendees add applicable sales and local taxes**
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________ Subtotal (Required items + sales tax)
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________ Total (Required subtotal + Optional subtotal)
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*** Registration for coordinator or military member discount must be completed online
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**** All prices are shown in US Dollars ****
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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.
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Mail Code or VIP #: |
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First Name: |
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Last Name:
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Profession: |
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Note: Leave Company/Department blank if providing home address |
Company Name: |
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Department: |
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Address: |
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City: |
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State: *
Zip: *
County: *
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Work Phone: |
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Cell Phone:
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Fax Number:
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Email Address: |
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License Number: *
(required for confirmation of registration)
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Prepayment is REQUIRED |
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Check enclosed
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Signed Purchase Order enclosed
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Credit Card Type: |
Mastercard
Visa
Amex
Discover
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Credit Card #: |
V-Code #*
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Exp Date: |
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*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: |
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Mail or Fax to:
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PESI, P.O. Box 1000, Eau Claire, WI 54702-1000 (800) 554-9775 (fax number) |