RTBAV Seminar Registration Application

Please PRINT OUT This Application Form, Fill It Out, and Mail It To The Address Below, OR

If Using A Credit Card, You May Optionally APPLY BY TELEPHONE By Calling 207-846-3000

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CONFIDENTIAL Seminar Registration Application

Date of Requested Seminar: _____________

NAME: _____________________________________________________________________________

MAILING ADDRESS: _____________________________________________________ APT #: ______

CITY: _______________________________________________ STATE: _________ ZIP: ___________

E-MAIL ADDRESS: __________________________________________________________________

BIRTHDATE: _______________ WORK TEL: _________________ HOME TEL: __________________

Payment Method: qCheck or Money Order Enclosed qCredit Card

NOTE: Check or Money Order Should Be Made Payable To: "Media Guys Inc"

If Paying By Credit Card (MasterCard or VISA), Please Provide The Following Information:

NAME ON CREDIT CARD: __________________________________ TYPE OF CARD: ____________

ACCOUNT #: ____________________________________________ EXP DATE: _________________

SIGNATURE: _____________________________________________
Please Mail This Completed Application Along With The Appropriate Payment To:

Jeff Weinstein, RTBAV Certified Instructor

PO Box 373

Yarmouth ME 04096

Any Questions? Please Call 207-846-3000

Please Allow Approximately Two To Four Days For Processing

Thanks!

Your Enrollment Will Be Acknowledged By E-Mail or Telephone