Keeping the Love You Find Registration Form
Name__________________________________________________
My nametag should read________________________________
Address_______________________________________________
City__________________________________________________
State_________________________Zip_____________________
Home ( )________________Work ( )__________________
Fax ( )_________________Email_______________________
Referred by___________________________________________
Date of workshop______________________________________
Method of Payment
_ Check
_ Visa/MC/AmEx #______________________________________
Exp. Date__________________________
$ Amount__________________________
Card Signature________________________________________
Make checks payable to Beverly S. Talan, Ph.D.
and mail with this registration form to:
380 N. Old Woodward, Suite 156, Birmingham, MI 48009
Or Fax to: (248) 626-8089
Sign up Soon - Space is Limited!
Workshop Location: 380 N. Old Woodward, Suite 156, Birmingham
The registration fee is $325 per person if paid 3 weeks
in advance or $350 if paid less than 3 weeks before the
workshop begins. A deposit of $175 will reserve a place
for you. The balance is due one week before the workshop.
The fee includes a workbook and coffee/refreshment breaks.
Cancellation Policy: If you withdraw 8 days or more prior
to the start date of the workshop, your fee will be refunded,
less a $75 administration fee. For withdrawals made 7 days
or less prior to the start of the workshop, your fee is
non-refundable, but can be transferred to the next workshop.