| Name (as you'd like it on your certificate): ___________________________________________________________________ |
| Address: ___________________________________________________________ |
| City: _________________________________________ State: ________________ |
| Zip: ____________________ Phone(s): ___________________________________ |
| Email: _____________________________________________________________ |
| For Credit Cards: _____ Visa ____ MC ____ Discover ____Amex |
| Cardholder's Name: _________________________________________________ |
| Card #: ___________________________________ Exp. Date: ___________ |
Signature: ___________________________________________ |
If credit card billing address differs from the above address, please include your billing address here |
_________________________________________________________________ |
_____ Yes, I have a massage table I'm willing to bring. |
Amount Enclosed |
| ____ $600 Registration _____ $100 deposit |
| _____ Please charge the remaining balance on Nov. 1st |
| ______ I will pay the remaining balance by mail or by calling in at a later date |
Checks should be payable to Sacred Lomi, LLC |