Contact Information | Shipping Address (if different) |
| NAME _________________________ | Name _______________________ |
| FIRM __________________________ | FIRM ________________________ |
| ADDRESS _____________________ | ADDRESS ___________________ |
______________(No PO BOXES, please) | _____________________________ |
| CITY __________________________ | CITY ________________________ |
| STATE _______ ZIP _____________ | STATE _________ ZIP __________ |
| PHONE __________ FAX _________ | PHONE ________ FAX __________ |
Please indicate method of payment | Mail or Fax to: |
| ___ Check Enclosed ___ Bill Firm | Center for Professional Seminars |
| ___ MasterCard ___ Visa ___ Amex | 40 Lake Bellevue Drive, Ste. 101 |
| Name on Card _______________________ | Bellevue, WA 98005 |
| Signature_____________________________ | |
| Card No _______________________ | FAX: (425) 637-2872 |
| Exp. Date_____________________________ | PHONE: (425) 646-4020 |
