Total Immersion Los Angeles, CA $500 Deposit


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Student Registration Form

Please use the name of the student you are sending to the class in the Customer Information area and the correct credit card billing address for the rest of the form (this does not have to be the students mailing address). Also, since this is where the student will be coming for the 4 weeks of Aftercare, you will need to set up a User Name and Password and use their correct email address. If you have more than one student attending you will need to fill out and individual form for each .

Customer Information

Please Use Credit Card Billing Address!

First Name [ required ]
Last Name [ required ]
Company
Address Line 1[ required ]
Address Line 2
City [ required ]
State [ US & Canada ]
State/Province [ All other Countries ]
Zip/Postal Code [ required ]
Country [ required ]
Your E-mail Address [ required ]
Phone Number [ required ]

Shipping Information

Shipping same as billing address

Ship To First Name [ required ]
Ship To Last Name [ required ]
Ship to Company
Ship to Address Line 1[ required ]
Ship to Address Line 2
Ship to City [ required ]
Ship to State [ US & Canada ]
Ship to State/Province [ All other Countries ]
Zip/Postal Code [ required ]
Ship to Country [ required ]

Class Enrollment Form

Class Enrollment:	Los Angeles, CA Student Deposit ($500.00) The Early Bird Special has a balance of $1497 for each student registered and will be charged automatically on the same card (unless otherwise notified) on November 11, 2012.

Choose LOGIN Name [ required ]

Choose PASSWORD [ required] must be at least six characters long, using alphas and numbers, no spaces

Confirm PASSWORD [ required ]

Deposit Payment Information

Payment Method [ required ]
Credit Card Number [ required ]
Credit Card Security Code [ required ?]
Expiration Date [ required ]	/
Name on Credit Card [ required ]
Is this a Renewal?
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