Coaching Registration If you are human, leave this field blank. Name * First Last * Last Address * Address Address Line 1 Address Line 1 Address Line 2 (optional) Address Line 2 (optional) City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Home Phone: * Work Phone: Mobile Phone: * Sex: Birthdate: * Email: * Person who shared Pathways with you (your sponsor): * Which coach would you like to work with? * Please choose one Sue Paige Amanda Bolivar Terms & Conditions: Coaching packages must be paid in full at time of purchase. In the space below enter the full amount of the coaching package you have selected. For credit card charges: By posting this electronic registration form with the following credit card information, you authorize Paige, Martin & Associates, Inc. (Pathways to Successful Living Seminars) to charge the full price of the coaching package to my credit card account. Choose a coaching package: * Please choose one 1 Session: $200/hour (Sue Paige) 3 Sessions: $547 (Sue Paige) 5 Sessions: $897 (Sue Paige) 10 Sessions: $1697 (Sue Paige) 1 Session: $150/hour (Amanda Bolivar) 3 Sessions: $415 (Amanda Bolivar) 5 Sessions: $675 (Amanda Bolivar) 10 Sessions: $1275 (Amanda Bolivar) Name (as appears on card): * Credit Card Type: * Visa Mastercard American Express Account Number: * CVV Code: * Expiration Date: * Acknowledgment of Terms & Conditions: By signing below, I acknowledge that I have read, understand and agree to to all of the above terms and conditions. Signature * Draw It Type It Clear Submit