Please complete registration information
below. Check appropriate program for which you wish to register, payment
option, and amount enclosed. As appropriate, either enclose check or money
order or complete credit card information. For check or money order, mail to:
Summitry Coaching c/o PSP, 9912 Business Park Drive,
Suite 170, Sacramento, CA 95827 USA. For credit card order, either mail to
above address, fax to + 916-364-5511, or e-mail to pattie@psp.edu.
First Name: _________________________
Family/Surname:_________________________
Title (Optional):
______________________
Organization (Optional):
_____________________________
Mailing Address:
___________________________________________________________
City: ________________________
State/Province: ______
Postal Code: __________
Country: ___________
E-Mail Address:
____________________________________
Telephone Number:
_______________________
___________________________________________________________
2006 Program for which You Wish to
Register:
_____Washington D.C.- May 17-18, July 22-23
& September 26-27, 2006
_____Chicago (Illinois)- August 23-24,
October 21-22 & December 5-6, 2006
_____Harpswell (Maine)- June 21-22, August
12-13 & October 10-11, 2006
______________________________________________________
Payment
Option
_________ Option One: $5000 (Total)
[$5000 due at registration]
_________ Option Two: $5,500
(Total) [$3000 due at registration/$2500 due at 2nd
Workshop]
_________ Option Three: $6000
(Total) [$2000 due at registration/$2000 due at 2nd
Workshop/$2000 due at
3rd Workshop]
_____________________________________________________
Payment Method
(Please make payment in U.S.
dollars to “The Professional School of
Psychology”)
____Check
Check Number:
________________ Amount: US$ __________________
___________Credit
Card ______________Visa ___________MasterCard
Check appropriate card
type
Card Number:
______________________________________
Expiration Date(mm/yy):
____________
Signature:
__________________________________
Name on Card:
________________________________
