REGISTRATION

Please reserve ___place(s) for the seminar at a cost of $________

Total Canadian $______

Name:____________________________________________

(As you wish it to appear on your name badge)

Contact Address ___________________________________

__________________________________________________

Residence telephone: _______________________________

Business telephone: ________________________________

Cell : _____________________________________________

Fax: _____________________________________________

Email: ____________________________________________

I enclose a cheque for $_________________

Made payable to Pacific Coast Seminars

Please debit my

American Express, VISA, Master Card

please circle

Number: __________________________________________

Expiry Date: _______________________________________

Card Holder Signature: _______________________________

Card Holder Address: ________________________________

Please send your complete booking form to:

Pacific Coast Seminars

Box 2463,

Sidney,

British Columbia

V8L 3Y3

Canada

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