East Point Seminars Registration

EAST POINT SEMINARS - REGISTRATION FORM

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Name: ____________________________________________________________________

Address: __________________________________________________ _______________

Street Apt. #

_____________________________________ ________ ________________

City State Zip

Phone: _______ ____________________ Alternate #: ______ ___________________

Email: ___________________________________________________________________

Please list the classes for which you are registering:

___________________________________________________________________________

Amount of Payment: __________________

Form of Payment (circle one): Check Money Order Credit Card

(We accept Visa, Mastercard, Discover and American Express)

If paying by credit card, please fill in below:

Credit Card #: _________________________________

Exp. Date: ________________ Card Code: ________

Name on Card: ________________________________

Authorization (signature): ________________________

Please fax, mail or email this form to:

East Point Associates, Ltd.

1525 East 53rd Street - Suite 705

Chicago, Illinois 60615

773-955-1470 Fax

For more information contact:

Mary J. Rogel

773-955-9643

773-955-1470 Fax