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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 ______.  If an attorney, # of years practicing family law: _______

Address __________________________________________________________________________

______________________________________________ Zip ___________

______ $80 for textbooks: These books are required for basic training. This payment may be added to your other check or charge).
______ $1,450.
______ $450 deposit. Balance of $1,000 is due before starting.
______ $1,325 (early registration fee). Due 30 days before starting date.
______ $_________ ($1,225 for each person from the same group). Due 30 days before starting date.

Please send check and this registration form to:

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.

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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: