Leadership Excellence Coaching Group Registration Form

Name: _______________________________________

Group are you interested in joining:    _____ Group I    _____ Group II?

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 of credit card:




Please debit my credit card in the amount of $165 and charge my credit card
$165 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 your registration to our secure fax: 301-587-4327.
Thank you!


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Ellen Ostrow, Ph.D., CMC

910 17th Street N.W.
Suite 306
Washington, D.C. 20006
Phone: 844-818-9471
Fax: 301-587-4327