Promotional Workshops

Full Name:

Email:

1. Please Indicate Which Location You Will Attend: * Required

	Newark, CA Newark Silliman Center February 8th, 2012 Assessment Center (See Flyer)
	Newark, CA Newark Silliman Center February 9th, 2012 SimulatorWorkshop (See Flyer)

	Anaheim, CA February 11th, 2012 Assessment Center (See Flyer)
	Anaheim, CA February 12th, 2012 SimulatorWorkshop (See Flyer)

	Scottsdale, AZ Scottsdale Public Safety Training Center February 14th, 2012 Assessment Center (See Flyer)
	Scottsdale, AZ Scottsdale Public Safety Training Center February 15th, 2012 SimulatorWorkshop (See Flyer)

2. Sign Up For: * Required

	Assessment Center Seminar	$110.00
	Simulator Workshop	$110.00
	Total:

3. Method of Payment:

*Cancellations must be made up to one week prior to scheduled class date.
No refunds will be made for "No-Shows". You may
be able to attend another scheduled class, space provided.

Check Mailed - Please include payment with copy of Registration Confirmation.

Visa or Master Card (3% service charge will be added)

Pay at The Door, Cash or Check $120.00 per Class Day

Bill My Department - Must have Department PO

Payments must be made directly through me by email or by phone.
** Must have Department PO

4. Student Information:

First/Last Name:
Address:
City:
State:
Zip:
Department:
Phone #:
E-mail Address:

5. Billing Information:

Billing Address
First Name:
Last Name:
Company (optional):
Street Address:
Street Address (2):
City:
State/Province:
Zip/Postal Code:
Country:
Phone:

Credit Card
Credit Card Number:	* Required
Expiry Date:	* Required
CV2 security code:	* Required

On most cards, the security code number is the last three digits of the number printed on the back, at the top right of the signature strip.

* Required Fields

CHUCK WILSON
77-263 Maliko Street
Kailua Kona, Hawaii 96740
For Info: (808) 987-0038
Fax: (808) 322-7009
promotionalworkshops@gmail.com

E-mail

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