Registration Form for The Center of Light Programs
The Center of Light in Vermont
for all programs and services
Phone: 802.674.9585; Fax: 802.674.9586; E-mail: info@sunreed.com
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With my signature I acknowledge and accept the conditions of this workshop & registration as set
forth in the information pages contained in The Center of Light's Registration web pages.
Name
...............................................................................................................................................
Address .........................................................................................................................................
Telephone/Fax …………………………………………………………………………………….................
E-mail Address .........…………………………………………...........................................................
Name of Workshop I wish to attend ..............................................................................................
Date of workshop ................................................ Full Cost of workshop: ...............................
Enclosed is .................................... for deposit; or, ............................... for payment in full
or, charge to my credit/debit card, this amount ........................................ for deposit,
or ............................... for payment in full. (All funds in US Dollars)
If deposit, pay balance
on my credit/debit card (amount) .............................. on (date)..............................
Address .........................................................................................................................................
Telephone/Fax …………………………………………………………………………………….................
E-mail Address .........…………………………………………...........................................................
Name of Workshop I wish to attend ..............................................................................................
Date of workshop ................................................ Full Cost of workshop: ...............................
Enclosed is .................................... for deposit; or, ............................... for payment in full
or, charge to my credit/debit card, this amount ........................................ for deposit,
or ............................... for payment in full. (All funds in US Dollars)
If deposit, pay balance
on my credit/debit card (amount) .............................. on (date)..............................
For
Credit/Debit Card Payment (MC, VISA,
or AmEx only): mail, fax or call
with card #, expiration date, name on the card, and your billing address for the card.
with card #, expiration date, name on the card, and your billing address for the card.
Card
Number
....................................................................
Ex Date:
................................
If different:
Name on Card: .................................................... Billing address: ...................................................
................................................................................................
Date ………………………………… Signature..........................................................
To register on line, go to our Secure page, and fill in the workshop title on the
"instruments' line (no other fees apply on the secure order form.)
If different:
Name on Card: .................................................... Billing address: ...................................................
................................................................................................
Date ………………………………… Signature..........................................................
To register on line, go to our Secure page, and fill in the workshop title on the
"instruments' line (no other fees apply on the secure order form.)
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The Center of Light in Vermont
Zacciah Blackburn, 220 Hidden Glen Rd. , P.O. Box 389 , Ascutney, VT 05030 USA
Phone: (802) 674-9585 Fax: (802) 674-9586 E-Mail info@sunreed.com C 2005 Zacciah, The Center of Light
The Center of Light in Vermont
Zacciah Blackburn, 220 Hidden Glen Rd. , P.O. Box 389 , Ascutney, VT 05030 USA
Phone: (802) 674-9585 Fax: (802) 674-9586 E-Mail info@sunreed.com C 2005 Zacciah, The Center of Light