|
Training Programs > Registration Form
 Print this <-- Click here to print this page OR click to download registration form in Adobe PDF format. )
42 Hour Basic Training in Divorce Mediation Start Date: ___________________
Name ____________________________________________________________________
(Please Print Name Exactly as You Wish it to Appear on Your Certificates)
Profession/occupation _________________________Degree ________ Year ______
Address __________________________________________________________________________
______________________________________________ Zip ___________
Phone Home (_____)____________________Work (______)______________________
Fax Number (______)_____________________ E-mail __________________________
I Heard about the Training Program From: _________________________________________________________________________
PAYMENT INFORMATION
Choose method of payment: ____ Check enclosed.
(Please make all checks payable to "Center for Mediation & Training.")
__ Charge my credit card: __ Visa __ MasterCard __ American Express.
Credit card number: ____________________________________________________
expires: mo: ______ yr: ______
Amount of check or charge:
______ $75 for textbooks: These books are required for basic training. This payment may be added to your other check or charge).
______ $1,275.
______ $275 deposit. Balance of $1,000 is due 1 month before starting.
______ $1,150 (early registration fee). Due 30 days before starting date.
______ $_________ ($1,050 for each person from the same group). Due 30 days before starting date.
Please send check and this registration form to:
Ken Neumann, Townhouse B
111 West 90th Street
New York, NY 10024 | If you are charging you may mail, or fax to: 212-721-1012
If you have any questions, or would like to register for an Advanced Training Course, please call (800) 613-4867 or (212) 799-4302 (Ken Neumann) or (914) MEDIATE (Steve Abel).
Click here to download registration form in Adobe PDF format.
Don't have Adobe Acrobat Reader? Download Adobe Acrobat Reader here.
|
|
