Registration
Form
Fax form to (321) 751-6111 or call (800) 558-2197 or
(321) 751-7001
VISA, MasterCard, American Express, Check & Money
Orders accepted
Make
checks payable to:
Healing Light Seminars
279
N. Babcock St.,
Melbourne, FL 32935
Indicate seminar date you are registering for in space
provided
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____ Seminar $400, if
payment is received
30 days prior to seminar
____ $450.00 if paid thereafter
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____ Students
$200, if payment is received
30 days prior to seminar
____ $225.00 if paid thereafter |
Discounts:
- $50.00 regular discount ____ $25.00
student discount ____ is granted to members of AAAOM,
FSOMA and other state acupuncture/OM associations
as well as to chiropractors, dentists,
medical doctors, naturopaths, physical therapists,
podiatrists or students of same with verified proof of
membership to their respective national or state associations.
- Two or more people signing up
together receive $50.00 off each.
- Two or more students signing up together receive
$25 off each.
NOTE: Students must be enrolled in
an accredited institution at time of registration. To
receive discount for two persons registering together,
both registrations must be submitted at the same time
for the same seminar. Healing Light Seminars, grants
a maximum discount of $100 for practitioners and $50
for student.
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Name__________________________________Company_______________________________
Billing
Addres_________________________________________________________________
City____________________________ State______________ Zip
Code________________
Phone Number (______)______________________
Email_____________________________
Medical
License held __________________Medical License # _____________ State
______
Seminar you are registering
for:
Date:_________________ City:________________________
State:________________
Payment: ___Check
___VISA ___MasterCard ___American Express ___Money Order
Card#_______________________________
Exp Date_______________
Billing
Address______________________________City________________________ST_____
Phone
# affiliated with credit card________________________
Signature
____________________________________________
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