| Are you an intern? If yes, your
program begins March 1st.
Yes
No
|
Name (First
and Last):
(If
you are paying for more than one person, please
fill out a separate form for each attendee. Thanks!) |
| Mailing Address:
(include apartment numbers
or suite numbers) |
|
City:
|
State:
|
| Zip/PostalCode:
|
Country:
|
| Home Telephone
(w/ area code):
|
| Cell Phone
Number:
|
| Work Telephone
(w/ area code):
|
Email
Address:
IMPORTANT! |
Dietary
Choice:
Special Dietary Information (we
will accomodate special diet within reason)
:
|
ROOMING
(check one):
Double Occupancy OK
Roommate Name (if known):
|
Single
Room ($450 extra)
(availability
on limited basis) |
| SMOKER:
No
Yes
|
TRAVEL:
Flying
Driving
Shuttle: Yes
No
|
If
flying, we need your travel itinerary in detail
when known. Please call, fax or email your information.
You may also enter it below in the comments section. |
| Payment Method:
|
| Authorized
Amount:
|
Credit
Card Number:
Expiration Date:
3-Digit Security Code
on back (4-Digit on front, if AmEx) of card:
|
Does your
credit card statement mail to the address supplied
above?
Yes
No
.
If no, please supply statement billing address:
|
How did
you learn about this retreat?
If you did an internet
search, what keyword did you use, if you remember?
|
| ADDITIONAL
COMMENTS OR YOUR FLIGHT INFORMATION IF KNOWN
NOW:
(Airline Carrier, Departure City, Flight Numbers,
Connecting City and Flight Number, and Departure
time on final day.)
Do you need a response
to your comment?
(If
yes, please make sure you give us your email
address and phone number in the appropriate
fields above.) |
| By
pressing the "send" button, you
are authorizing Eupsychia, Inc. to charge
your Credit
Card the amount you have indicated above...
|
|
•••••
THANK YOU!
|
