Divorce & Custody (Domestic Relations) Mediation Training

To be used for workshops held in Ann Arbor or Chicago. To register for all other workshops, please contact the local host organization directly.

Name	________________________________________
Address	________________________________________
	________________________________________
	________________________________________
	________________________________________
Work Phone	(_____)-_________________________________
Fax	(_____)-_________________________________
Home Phone	(_____)-_________________________________
Cell Phone	(_____)-_________________________________
E-mail	________________________________________
Occupation	________________________________________
Education	_______________________________________
Training Date	________________________________________
Training Location	________________________________________
Where did you hear about our class?	________________________________________
Where did you hear about our class?	________________________________________

Form of Payment

Amount $_________ (U.S.)

___ Check:

(Check No. __________)

___ Money Order:

(Order No. __________)

___ Credit Card:

___ Visa ___ MasterCard ___ American Express
Card Number	____________________________
Card Security Code *	___________
Expiration Date	____________________________
Authorized Signature	____________________________
Date	____________________________

* The Card Security Code is requested as an additional security precaution. For American Express, the code is a 4-digit number on the front of the card, just above the credit card number. For Visa and MasterCard, the code is a 3-digit number printed on the back of the card in the signature panel, where it follows the last four digits of your card number.

Mediation Training & Consultation Institute
330 E. Liberty St., Suite 3a, Ann Arbor, MI 48104
Phone: (800) 535-1155 or (734) 663-1155; Fax: (734) 663-0524;
E-mail: info@learn2mediate.com; http://learn2mediate.com