Getting the Love You Want

Registration Form - "Getting the Love You Want"

Workshop Dates:
 
Name:
Street Address:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
Email:
Status:

Partner's Name:
Partner's Address:
Partner's City:
Partner's State:
Partner's Zip:
Daytime Phone:
Evening Phone:
Email:

Method of Payment:
Check MasterCard VISA AMEX
Credit Card #:
Expiration:

Cost & Confirmation:
$325 Deposit with this registration to guarantee your space. The $325 balance is due one week prior to the workshop.

Payment by Check:
If you are paying by check: In order to guarantee your space we must receive your check within 5 business days. Complete this form, print and mail, with checks payable to:

Michael H. Borash, LPC, P.C.
1388 Old Bridge Road
Woodbridge, VA 22192

Payment by Credit Card:
By submitting this form, I authorize Michael Borash to charge my VISA/MasterCard/AMEX account the amount above.