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 _________________________________________________________
