Navigating Career Transition Coaching Group Registration Form

Name: ________________________________________________________

E-mail address: _________________________________________________
                                   (Please print V-E-R-Y CLEARLY)

 
Payment information:  (Select one)

____ Visa   ____ MasterCard   ____ American Express

Credit Card Number: _________________________________________

Expiration date:__________________________

Name (as it appears on card): _______________________________________

Exact billing address for card:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Please debit my credit card in the amount of $249 and charge my credit card
$249 in advance for each month of group coaching calls. The client may
discontinue automatic debit at any time by notifying the coach.

Signature: _________________________________________

Date: ___________________________________

Please fax Registration to our Secure Fax:  213-995-9834.

Thank you!