Repair Workshop Online Sign Up Form

Name *
E-mail Address *
Store NAme *
Street Address *
City, State, Zip *
Phone *
Fax
Main Attendee Name
Additional Attendees Names
Do you use a copy of Geller's Book now?	No Yes - Version 5.0 Yes - Version 4.0 (Release 9 or 10) Yes - Version 4.0 (Release 1 - 8) Yes - Version 3.5 Yes - Version 3.2 Yes - Version 2.0 Yes - version 1.0
Credit Card Type *	American Express Visa/Mastercard Discover
Card Number *
Expiration Date
V Code (Last 3 digits on back of the card at the end of the white strip. For AMX=4 digits on front of the card) *
Workshop Registration "Fill in $749.00" *
If bringing in more than 1 attendee, $179.00 X the additional attendees. Put TOTAl here
Subtract $100 by registering by May 1st (type -$100)
Total Registration Fees (please add and type here) *

* Fields marked with an asterisk are required fields

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