Seminar instructor - Date of seminar / / 05
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Your name (last) _________________________ (first) _______________ Date of birth____/____/________
Home address Street______________________________ Apt # ________
City ____________________________ State _______ Zip _________________
Phone # ________-________-_____________ E-mail address ___________________________________
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Method of payment Prepaid with credit card ___ Prepaid with check ___ Pay at the door cash only! ___
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Business information (if you're representing a school, agency, institution etc.)
Name of business ___________________________________________________________
Street address _______________________________________ Suite # ________
City ____________________________ State ______ Zip _________________
Phone# ________-________-____________ E-mail address ____________________________________
___________________________________________________________________________________________
In case of an emergency I would like you to contact
(last name)___________________________ (first name) __________________
Phone # ________-________-____________ Alternate phone # ________-________-____________
E-mail _______________________________ Your relation to this person ____________________________
Address Street ______________________________ Apt. #________
City ___________________________ State ______ Zip _________________
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Where did you hear about this seminar? You have attended our events in the past ____
On the Michael Janich's web site ____ Found The RealJitsu Academy web surfing ____
Martial arts event web site ____ Received an e-mail ____ Received a flyer at another event____
Card in a book or magazine ____ Saw a flyer in a storefront ____ Friend/word of mouth ___
From your martial arts instructor ___ If so, who?__________________________
Other ______________________________________________________________________
