Name

First MI Last

Address

City/Town

    State     Zip  

Phone (Day)

   Phone (Evening)  

Email

CEC's


CEC's
(No Charge)

     Certification Number 

     Certification Number 


Refund Policy:  Lifestyle Management Associates offers a refund, less shipping and handling, within 14 days of purchase provided the materials are returned unopened and in saleable condition. Credit may be applied to other courses through Lifestyle Management Associates from 15 to 30 days after purchase.  All materials are warranted and will be replaced at no charge.


Payment Information (Print for mail-in or secure fax orders only)
(Credit Card information will not be sent over the Internet)

Cost: $359 plus $10 shipping and handling for a total of $369

Payment type   Check by mail     Credit Card by mail     Credit Card by Secure Fax

Credit card type         Master Card     Visa

Credit Card Number

Expiration Date

Name as it appears on card

Credit Card Billing Address

City/Town         Zip Code

 

 

Signature ________________________________________________(Sign the form)

First print completed form. Sign the form, then Fax or mail completed form to address above.

Please include check if applicable.