* An asterisk indicates a required field.
First Name* Last Name* Title Organization Mailing Address* Address (cont.) City* State/Province* Zip/Postal Code* Country* Work Phone* Home Phone FAX E-mail* URL
PAYMENT INFORMATION
Payment option* <Select a method of payment> Visa MasterCard American Express Discover Check Money Order Credit Card Information (Disregard if not paying with a credit card) Name as it appears on your credit card Expiration date (month/year) Billing Address Address (cont.) Billing City Billing State/Province Billing Zip/Postal Code Billing Country
Credit Card Information (Disregard if not paying with a credit card)
CONFIRMATION
I am enrolling <select number of enrollees> 1 2 3 4 5 6 7 8 9 10 people in the Marriage Seminar. (Note: If you are enrolling anyone other than yourself, please note the names and addresses of the other attendees in the Comments section below.)
I understand that the cost of a seminar is $360 per couple, or $230 per single person. The cost of the seminar includes lunch. For anyone who does not already have a WIDP Profile, I understand I must also pay $40 per person to get my WIDP Profile.
By my signature below, I agree to allow Worley ID Profile to charge my credit card for the <select amount you are paying now> minimum deposit of $50 per person $230 (the full cost of the seminar) $230 (the full cost of the seminar) plus $40 for a profile, for a total of $270 $130 (the full cost of the seminar for ALUMNI ONLY) , unless I am paying by alternate means. (Note: If not paying with a credit card, please enclose a minimum deposit of $50 per person when you mail this form.)
PLEASE REVIEW THIS FORM CLOSELY FOR ERRORS BEFORE SIGNING.
Signature: ________________________ Date: _______
COMMENTS
Print, sign, date, and mail or fax this form to:
Worley's ID Profile 44 Farmers Row Groton, MA 01450-1802 Tel: 978.448.2047 Fax: 978.448.3910
(For registration by credit card, you may opt to fax this form, rather than mailing it.)
NOTICE: WE RESERVE THE RIGHT TO CANCEL ANY SEMINAR IF THERE ARE NOT A SUFFICIENT NUMBER OF REGISTRANTS. IN SUCH CASES, A FULL REFUND WILL BE PROVIDED OF ALL DEPOSITS AND PAYMENTS FOR THE CANCELED SEMINAR.
After you have printed this form, click here for information regarding travel arrangements.