Name

First MI Last

Address

City/Town

    State     Zip  

Phone (Day)

   Phone (Evening)  

Email

Course Date

     Course Location  


 

18 Hour Nutrition for Professionals Course
                  (Course cost $299)
 $

CEC's 1st Org.
 Certification #
 $

CEC's 2nd Org.
Certification #

 $
 $

CEC's 3rd Org.
Certification #

CEC's 4th Org.
Certification #

 $

Late Fee
Check if it is 10 days or less prior to class date
 $

Sub Total of Course   
 $

Nutrition for Professionals manual is a required text book for the couse.

   

Bound Manual

  

Manual $65.00 (Required)
$

Shipping and Handling
$

Sub Total
$

Total Cost of Course and Materials
$
   

Confirmation and directions will be mailed to you upon receipt of completed registration form. Space is limited. Pre-registration is required. A refund will be given for cancellations with 30 days notice prior to the beginning date; however, a charge of $50 will be applied for handling/shipping costs. Additional charge will be applied for materials not returned. All returned items must be in sellable condition. All other cancellations will be credited toward future workshops. A $50 charge will be applied for changing/switching course dates. A 24 hour notice is required for any credit.


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

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.