NMT REGISTRATION FORM

NMT CENTER
900 14th Avenue North
St. Petersburg, Florida 33705
727-821-7167
727-822-0643 (FAX)


Register now with your Visa or Mastercard on our secure server!


SEMINAR INFORMATION
(A $50 Late Fee will apply if posted less than 4 weeks before scheduled event.)

Seminar Title:
Cervical/Cranium If seminar information is incorrect, click here.
Date:
Jul 13-15, 2012 * A $50 Late Fee will apply. Waiver request below.
Sponsor Site/Location:
Spokane, WA
Educational Investment:

ENHANCED Format:
Torso/Pelvis, Cervical/Cranium,
Upper Extremity, Lower Extremity
$495 or $295 (Reviewer)

Are you a reviewer?
NOTE:
If you were previously certified by NMT Center Seminars, a NMTC School Program, or in the St. John Method, rates are the same as reviewer.
 
Will you bring a table?


Please list any
previous NMT courses
you have taken:



To ensure your reservation, please fill in all information.

BILLING INFORMATION
(Fields marked with an * are required.)

* First Name:
* Last Name:
* Address:
* City:
* State:
* Zip: (12345-1234)
* Daytime Phone:
(555) 555-1212
Evening Phone:
(555) 555-1212
E-mail:

*PAYMENT INFORMATION

By Mail:
I will mail payment
 


If paying by mail:

Please attach your payment in full or non-refundable $100 deposit to a copy of your NMT registration data form. If mailing less than four weeks prior to a seminar, please include your $50 late registration fee.

Deposit or payment in full must be received within 10 days before NMT Center can confirm your registrations. We are sorry, we can not hold registrations without deposit or payment in full beyond 10 days.

By Credit Card:
Master Card
Visa
  If Paying by Credit Card, Please Enter Information Below:
NMT Center is authorized to charge a $100, non-refundable
____ deposit to my charge card.


NMT Center is authorized to charge my full seminar
____ registration to my charge card.

   
* Name as it appears on card:
* Credit Card Number:
---
* Expiration Date
(MM/YY)
* Security Code:
(3 Digit Code on the Back of Card)
 
* Your registration indicates a late fee will be charged.
To request a waiver, please check box
and give brief explanation below.
  I request a change in late registration fee terms.
Please Explain:

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