 Laser Tattoo Removal Training Registration Form
Click here for a PDF version of the registration form
Enrollment - Choose Your Course
Houston, Texas |
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A.) March 26-27, 2011 |
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B.) May 28-29, 2011 |
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C.) July 30-31, 2011 |
London, England |
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A.) April 9-10, 2011 |
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| Name:__________________________________ Address:____________________________________________________ |
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City:_____________________ |
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State:_____ |
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Zip: _________ |
| Home Phone: (_____) _____________________________ |
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Work Phone: (_____) _______________________________ |
| Cell Phone: (_____) _______________________________ |
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Email: __________________________________________ |
Help us serve you better; complete the following questions:
| I am a: (cert or educ. not req) |
MD |
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PA/NP |
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MA |
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RN |
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Aesthetician |
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Tattoo Artist |
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Other: _____________ |
How did you hear about us? (check all that apply)
| Internet: |
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Which search engine did you use? (ie: Google, Yahoo, MSN) __________________________________________ |
| Which Keywords did you use: (ie: laser college)_________________________________________________________________ |
| Print Advertisement |
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Article |
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Postcard/Mailing |
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Seminar |
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TV |
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Trade Show |
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Other |
________________________ |
| (Referral) Name:___________________________________ (School) Name:_________________________________________ |
Payment
| Reserve My Seat Deposit ($250) |
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Pay In Full ($795) |
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Other |
________________________ |
| Check |
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Credit Card (Visa, MasterCard, Discover,& American Express) |
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Other |
_______________ |
| Card Number_________________________ |
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Expiration Date_______________________ |
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CCV # ________________ |
| Name on Card: ___________________________________ |
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Signature: ______________________________________ |
| Billing address (if different from above) |
| _______________________________________________________________________________________________ |
Print form and mail it or fax it to 713-623-2011 or call 713-783-2000.
Training Facility: 1770 St. James Place Suite 105 Houston TX 77056.
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