Please PRINT OUT This Application Form, Fill It Out, and Mail It To The Address Below

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CONFIDENTIAL Seminar Registration Application

Date of Requested Seminar: _____________

 

NAME: _____________________________________________________________________________

 MAILING ADDRESS: _____________________________________________________ APT #: ______

 CITY: _______________________________________________ STATE: _________ ZIP: ___________

 E-MAIL ADDRESS: __________________________________________________________________

 BIRTHDATE: _______________ WORK TEL: _________________ HOME TEL: __________________

Payment Method: qCheck or Money Order Enclosed

NOTE: Check or Money Order Should Be Made Payable To: "Media Guys Inc"

Please Mail This Completed Application Along With The Appropriate Payment To:

Jeff Weinstein, RTBAV Certified Instructor

PO Box 373

Yarmouth ME 04096

Any Questions? Please Call 207-846-3000

Please Allow Approximately Two To Four Days For Processing

Thanks!

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