FAX Registration


Simply print this page, fill in the requested information, fax the form to: (818) 362-3181, or mail-in the form.
Personal Information
Name:_____________________________________________
Address:___________________________________________
City:____________________ State:______ Zip:__________
Telephone Number: _______________________
Fax Number: _________________________
Email Address: ________________________________
Class Information
Name of Class: _____________________________________
Date of Class: __________________
Class Location: _____________________________________
Payment Information
MasterCard, Visa, or Discover
Card Number: ______________________________________ Last 3 digits on back of card _____________
Exp. Date: _________	Amount Charged $_______________
I authorize Consultants Extraordinaire to charge my card for this class. Signature: _________________________________________
The charge will posted on your monthly statement as: ProfessionalCharges.com
Mailing Address for Checks
Consultants Extraordinaire 12501 Rajah St. Sylmar, CA 91342