Divorce & Custody Mediation Training Registration Form

To be used for workshops held in Michigan 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?	________________________________________
	________________________________________

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.