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Coaching
Registration Form
Monthly
Video/DVD Coaching |
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Name:
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*E-mail:
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Telephone:
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Area of Coaching
Desired (check one):
Public Speaking
Preaching
Voice
Performance
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(In
90 words or less)
Indicate
your priorities in the area you are seeking to improve:
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(In 90 words or
less)
Currently what
are your major obstacles to achieving your goals in the area
you indicate above?
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Payment Form
Payment can be submitted online via secure credit card
(MasterCard or Visa only)
or by printing this form, completing it, and sending it via
fax or by mail. Checks
and money orders drawn on financial institutions within the
USA are also welcome. |
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Card Number
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Expiration date
of card (month/year)
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Name (as it
appears on credit card)
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Billing address
of credit card:
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Security Code
(last three numbers on back of credit card)
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Once this form has been completed,
print the form and
fax to: 717-728-2296
or mail to: P.O. Box 405, Enola, PA 17025 |
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Please make checks and money orders payable to Dr. Dilip R.
Abayasekara
Mailing address: P.O. Box 405, Enola, PA 17025, USA
Fax Number: (717) 728-2296 Telephone: (717) 728-2203 Email: drdilip@centralpenn.com
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