Please
print clearly.
Name________________________________________________________
Address_______________________________________________________
City / State
/ Zip____________________________________________
Phone number
office____________________________________________
Home phone
number__________________________________________________
Email_____________________________________________
There
are different options for registration so please read carefully.
Payment
Terms and Arrangements
Full
Course Tuition (level 1 –4) is $4,400
Option 1 -If prepaid in full $3,800.00 ( payment
must be sixty days before
course starts)
If you wish to prepay initial here_____ |
Option
2 -monthly payments -with a $1,400 deposit and
$650.00
autodebited on the first of each month after classes
start for the next 4 months
Initial here for the autodebit option________
|
-
Partial Tuition-
- Level 1 - $1,100.00
Single
Level - Prepaid Tuition Plan
If
you wish to register for only the first level initial
here_______
|
If
you have received information about classes and wish to attend,
call The Institute at 1-800-752-2232 or Email mail@naturaldentistry.org
I
plan to bring____staff members. I understand I will bring a
check or be autodebited on the day of the seminar for a cost
of $150.00 per staff member per day
Credit
Card Information
Name
(as it appears on the Card) _______________________________________
Billing
Address ____________________________________________________
City/
State/ Zip/ ___________________________________________________
Card
Number___________________________Expiration Date__________
Signature_________________________________________________________
Cancellation Policy - All cancellations need
a thirty day notification. A $350.00 processing fee will be
charged for all cancellations less then thirty days
Refund-Refunds
are subject to a $250.00 fee plus any cancellation fees applicable.
I understand and agree to the terms, conditions
and stipulations of this contract.
Signature__________________________________Date___________