Class Registration Form

You may either:
1. Complete and print this form and mail it to:
Equine Therapeutic Center, Inc.
Post Office Box 882
Hardy, VA  24101

OR

2. Complete and print this form, call 540-721-4545 and leave the requested information.

Description                                                                                  Price                      Total

EQ1110 Level 11 North Carolina, August 2012                          $995.00                  ______

EQ1100 Level I Ireland, August 2012                                            $1,195.00 USD         ______

EQ1110 Level II, Ireland, August 2012                                        $995.00 USD               ______

  TOTAL DUE:      ____________

NAME:  __________________________________________________________

ADDRESS:  _______________________________________________________

                       _______________________________________________________

CITY, STATE, ZIP __________________________________________________

PHONE:  _________________________________________________________

EMAIL ADDRESS:  _________________________________________________

MC/VISA CARD # ___________________________________________________

EXPIRATION DATE __________________________________________________

3 DIGIT SECURITY CODE ______________________________________________

SIGNATURE _________________________________________________________