Leadership Excellence Coaching Group Registration Form

Name: _______________________________________

Group are you interested in joining:    _____ Group I    _____ Group II?

E-mail address: ________________________@___________________________
                                 (Please print V-E-R-Y CLEARLY)
 
Payment information:  (Select one)
 
____ Visa   _____ MasterCard   ____ American Express
 
Credit card number: ________________________________________________
 
Expiration date: __________________________
 
Name (as it appears on card): _______________________________________

 
Exact billing address of credit card:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Please debit my credit card in the amount of $165 and charge my credit card
$165 in advance for each month of group coaching calls. The client may
discontinue automatic debit at any time by notifying the coach.
 
Signature: _____________________________________

Date: _________________________________________

Please fax your registration to our secure fax: 301-587-4327.
 
Thank you!