Please print out and mail if you are interested in signing up for the class, or call or email for more information.

Last Name:____________________Middle Initial:___First Name:____________

Address:_______________________________________________________________

City:___________________________State:______________Zip:_______________

Home Phone:____________________    Work Phone_______________________

email address:______________________________________________

Please print the title of the workshop or class
or body therapy session you are paying for:

________________________________________________________

Date and Time ___________________________________________


My method of payment is:
 __
|__| check/money order

__________________________________________________
Cardholder's signature required

__________________________________________________
Name, Area Code & Ph.# of Cardholder


Exp.Date:   |_|_|   |_|_|               month          year


Card Number  (please print clearly)

|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|


For Evenflow Body Therapy use only:  Date______/_____/_____

Auth.No._____________________  Ref.No______________________