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P.O. Box 1237 Lomita, CA 90717 Phone: (310) 325-9122, Fax: (310) 547-4603 E-mail: execofc@biokineticshealth.com Print & Fax or Mail In Registration Form |
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| Doctorate: | ||
| Office Address: | ||
| Mailing Address: | ||
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| Home Phone: | ||
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| E-mail: | ||
| Graduate Of: | ||
| City, State: | ||
| Degree In: | Year Received: | |
| Techniques I have studied: |
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| Therapies & Techniques I currently use in my practice: |
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| I use these for analysis: (Please check and/or describe where indicated) |
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| Muscle Test: _____ Leg Length: _____ Arm Length: _____ O-Ring: _____ | ||
| Other: _________________________ Other: _________________________ | ||
| Course Date: |
| Course Location: |
| Amount: (Check One) |
| First Time: Doctor $350 _____ Student $200 _____ New-Stim Stimulator when purchased with training $100 each ________ Refresher: $150_____ All fees include training manual. |
| Make checks payable to: Newsum Bio-Kinetics Check Number: _____ Total enclosed/authorized $________ |
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| Credit Card Type: (Check One) | |
| Visa: _____ Master Card: _____ Credit Card 3 Digit Security Code _____ | |
| Credit Card Number: | Expiration Date: |
| Name of Cardholder: | |
| Signature: | Today's Date: |
| Special Instructions: | |
| Learned of Seminar: ____ Referral ____ Print Ad ____ or _________________________ | |
* Prices subject to change without notice. 09/07 |