Name__________________________________________
Facility Name _______________________________
Home Address___________________________________
Facility Address_____________________________
Work Phone____________ Home Phone ______________
Current Certifications________________________
E-mail Address_______________________________
SS#________________________(this becomes your acct number)
Currently work as : _____ fitness instructor ____PE instructor ___Coach (which
sports)________________________
Registering for CEU’s Y ______ N ______ AFFA _____
ACE _____ Inservice Points _____ Other ______
Payment type: ______ mailed ck No. ___________ _______ money order amount paid
_____________________
Credit Card MC ______ VISA ______ AMEX ______ Name as it appears on the card
_______________________
Card Number ______________________________________________
Expiration Date __________________________
Print
this page and mail with check to:
If paying by credit card, you may fax this page to expidite this order (954) 435-5249