Last Name _____________________ First Name _______________ MI ___KARPAY AMERICA – NEW ENGLAND PROGRAM
April 30 - May 3, 2004REGISTRATION FORM
Please type or print clearly and mail or fax to the address below with your deposit.
Street Address________________________________________________________
City__________________________ State_____Zip Code_______ Country________
Tel. # with Area Code_______________ Fax # _____________ Cell ____ _______(opt.)
Emergency Contact and Telephone
Number______________
E-Mail Address____________________
Number of Persons Attending : __________
Disabled Persons : Special Requirements ____________________________________
Accommodations : Please see separate information on web site.
I am enclosing my Deposit of $ ______
( payable to The Center of Light )
I am authorizing the Center of Light to charge $_______ for
deposit ___ or payment in full ___
to my credit/debit card account: MC ___ VISA ___ AMEX
___ account number ________________________
Expiration Date: _____ Name on Card
________________________________
Billing address if different than above:
____________________________________________________________
Please print distinctly!!
Payment Information : The total cost
for the program is $ 485.- per person.
A discount for payment in full made by February 10, 2004 reduces cost
to $455.
A $ 100.- non-refundable deposit is
required with
your registration. The balance is due by
March 1, 2004. The program is
limited
to 30 participants.
Cancellation Policy
: Please
see
separate information on web site.
send to:
The
Center of
Light
Zacciah Blackburn
P.O. Box 389
220 Hidden Glen
Rd.
Ascutney,
VT
05030
USA
For credit
charges: this statement may take the place
of a credit
card sales slip. This charge will appear
on your credit card billing statement as
“Sunreed Instruments”.
This event is
sponsored by Barbara Perrins
and Cultural Immersion Travels of Richmond VA.
Contact information on website.
All policies and program content, etc, for this program are
governed by
C.I.T.
Top of Page
Top of Page
Top of Page
C 1991, 1999, 2000,
2001
R. Zacciah Blackburn, The Center of Light in Vermont
Home:
Center of Light