Anxiety Seminar Registration Form

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Registration Information

Seminar Name:
Seminar Cost:	$55/person (Payment Information)
Date and Time:
Your Name:
Address:
E-mail:
Comments:
Phone:

Early registration is recommened since seating is limited.

Seminar held at:

BirdSong Education and Counseling Services
8 Eagle Center Suite 3, O'Fallon, IL 62269
Tel.: (618) 624-1234 Fax: (618) 624-4618

Payment Information

Registration fee is $55.00. Advance registration is 10 or more days before your seminar date. Late registration ~ add $5.00.

No registrations at the door.

No refunds can be given within 5 days of your seminar date.

Please choose Method of Payment:

On-line Credit Card. I use

for on-line credit card transactions using MasterCard or Visa. To use Amercian Express or Discover, please choose a payment method below. Click here to pay on-line

Check. Print this form, make check payable to Birdsong Counseling, and mail to:

BirdSong Education and Counseling Services
8 Eagle Center Suite 3, O'Fallon, IL 62269

Or fax to: (618) 624-4618

Mail-in Credit Card. Fill out credit card information below, print this form and mail or fax to the address above:

Visa	MasterCard	Discover	American Express
Acct Number:		Expiration Date : (MM/DD/YYYY)
Name on Card:		Signature: _____________________________

Registration Information

Seminar Name:

Seminar Cost:

Date and Time:

Your Name:

Address:

E-mail:

Comments:

Phone:

BirdSong Education and Counseling Services 8 Eagle Center Suite 3, O'Fallon, IL 62269 Tel.: (618) 624-1234 Fax: (618) 624-4618

Payment Information

Send mail to George Bates with questions or comments about this web site. Last modified: February 02, 2010

BirdSong Education and Counseling Services
8 Eagle Center Suite 3, O'Fallon, IL 62269
Tel.: (618) 624-1234 Fax: (618) 624-4618

Send mail to George Bates with questions or comments about this web site.
Last modified: February 02, 2010