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 ($350 extra)
(availability
on limited basis)
SMOKER:
No
Yes
TRAVEL: Flying
Driving
Shuttle: Yes
No
(additional $80/round trip)
If flying,
we need your travel itinerary in detail. If you know it
now, please fill it out. If not, please call, fax or email
your information promptly.
Airline Carrier:
Originating City:
Flight Number:
Connecting City:
Connecting Number:
Arrival Time:
Departure Time on March 15th:
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 Eupsychia?
If you did an internet search, what
keyword did you use, if you remember?
ADDITIONAL
COMMENTS:
Do you need a response to your comment?
(If
yes, please supply email and phone numbers in above fields)
By pressing the "send"
button, you are authorizing Eupsychia, Inc. to charge
your Credit Card the amount you have indicated above...
THANKS!
WE'RE HAPPY TO RETURN TO GEORGIA AND THE CENTER FOR NEW
BEGINNINGS. WE LOOK FORWARD TO SEEING YOU THERE!
