CONTACT INFORMATION:

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 ($425 extra)

(availability on limited basis)
SMOKER: No Yes

TRAVEL (Arrive Aug 3. Depart Aug 9): 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 August 9th:

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 LOOK FORWARD TO SEEING YOU IN AUGUST!

To register by phone, call Brenda in the office, at 800.546.2795

Or, if you prefer to send a check or money order, please mail to:

Eupsychia, Attn: August 2007 6-Day, PO Box 151960, Austin, TX 78715-1960

 

 

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The Eupsychia Process Benefits... The Methods of The Eupsychia Process. © 2007 Eupsychia Institute, Inc. All rights reserved.