Coaching Registration - Pathways for Successful Living Courses

Personal Details

Student Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone*

Cell Phone*

Email*

Sex*

Birthdate*

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*

Payment Information

Discount Code

Total

$0.00

Credit Card Charges*

By posting this electronic form with the following credit card information, I authorize Paige, Martin & Associates, Inc. to charge my credit card account.

Credit Card Number*

Cardholder Name*

Credit Card Expiration Date*

CVV Code*

Card Holder Zip Code*

Terms and Conditions*

Please read carefully and check each box of the agreement.

By checking this box, I agree that my remaining balance will be charged to my credit card two weeks before the first day of my course, unless I call the office to arrange another payment plan.
I understand that if my balance is not paid in full by two weeks before the first day of my course, I will lose any discount I may have received.
I understand that if I am submitting this application less than two weeks before the first day of the course, I am not eligible for a discount.

By filling in my name and date below, I acknowledge that I have read, understand and agree to all of the above terms and conditions.

Name*

Date*

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Email

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