Lomi Lomi Workshop Fairfax Registration

Lomi Lomi
Registration
Form

Registration Form • Fairfax, VA • April 13-15, 2012

3 Day Lomi Lomi Workshop
Fairfax, VA • April 13-15, 2012
Sacred Lomi: Hawaiian Temple Bodywork
Earn 24 NCBTMB Continuing Education Hours
THIS FORM IS FOR PRINTING ONLY

Name (as you'd like it on your certificate): ___________________________________________________________________
Address: ___________________________________________________________
City: _________________________________________ State: ________________
Zip: ____________________ Phone(s): ___________________________________
Email: _____________________________________________________________
For Credit Cards: _____ Visa ____ MC ____ Discover ____Amex
Cardholder's Name: _________________________________________________
Card #: ___________________________________ Exp. Date: ___________
Signature: ___________________________________________
If credit card billing address differs from the above address, please include your billing address here
_________________________________________________________________
_____ Yes, I have a massage table I'm willing to bring.
Amount Enclosed
_____ $450 Full Registration
_____ $100 deposit _____ Please charge the remaining balance on _______________
______ I will pay the remaining balance by mail or by calling in at a later date
Checks should be payable to Sacred Lomi, LLC

Space is limited. Registration is on a first come, first serve basis. To guarantee your space, send $100 non-refundable deposit.
Sacred Lomi
PO Box 1206, Agoura Hills, CA 91376-1206 • Phone & Fax: (818) 865-8813
Workshop Location
Best Western Fairfax

We will send a welcome packet with a list of what to bring and a receipt two weeks before the class.
For specific questions about the class, please contact Tom or Donna at:
Sacred Lomi
(818) 865-8813 • www.SacredLomi.com

Home

Lomi Lomi
Registration
Form

Registration Form • Fairfax, VA • April 13-15, 2012

3 Day Lomi Lomi Workshop
Fairfax, VA • April 13-15, 2012
Sacred Lomi: Hawaiian Temple Bodywork
Earn 24 NCBTMB Continuing Education Hours
THIS FORM IS FOR PRINTING ONLY

Name (as you'd like it on your certificate): ___________________________________________________________________

Address: ___________________________________________________________

City: _________________________ State:

Zip: Phone(s): _______________

Email: _____________________________________________________________

For Credit Cards: _ Visa MC Discover Amex

Cardholder's Name: _________________________________________________

Card #: _________________________ Exp. Date: _

Signature: ___________________________________________

If credit card billing address differs from the above address, please include your billing address here

_________________________________________________________________

_____ Yes, I have a massage table I'm willing to bring.

Amount Enclosed

_____ $450 Full Registration

___ $100 deposit _ Please charge the remaining balance on _____________

______ I will pay the remaining balance by mail or by calling in at a later date

Checks should be payable to Sacred Lomi, LLC

Lomi Lomi Registration Form

Registration Form • Fairfax, VA • April 13-15, 2012

3 Day Lomi Lomi Workshop Fairfax, VA • April 13-15, 2012 Sacred Lomi: Hawaiian Temple Bodywork Earn 24 NCBTMB Continuing Education Hours THIS FORM IS FOR PRINTING ONLY

Name (as you'd like it on your certificate): ___________________________________________________________________

Address: ___________________________________________________________

City: _________________________________________ State: ________________

Zip: ____________________ Phone(s): ___________________________________

Email: _____________________________________________________________

For Credit Cards: _____ Visa ____ MC ____ Discover ____Amex

Cardholder's Name: _________________________________________________

Card #: ___________________________________ Exp. Date: ___________

Signature: ___________________________________________

If credit card billing address differs from the above address, please include your billing address here

_________________________________________________________________

_____ Yes, I have a massage table I'm willing to bring.

Amount Enclosed

_____ $450 Full Registration

_____ $100 deposit _____ Please charge the remaining balance on _______________

______ I will pay the remaining balance by mail or by calling in at a later date

Checks should be payable to Sacred Lomi, LLC

Lomi Lomi
Registration
Form

3 Day Lomi Lomi Workshop
Fairfax, VA • April 13-15, 2012
Sacred Lomi: Hawaiian Temple Bodywork
Earn 24 NCBTMB Continuing Education Hours
THIS FORM IS FOR PRINTING ONLY

City: _________________________ State:

Zip: Phone(s): _______________

For Credit Cards: _ Visa MC Discover Amex

Card #: _________________________ Exp. Date: _

___ $100 deposit _ Please charge the remaining balance on _____________