Internal Environment Institute
E-mail: francerobert@ieihealth.com Web site: www.ieihealth.com
Registration Form
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First NameMiddle NameLast Name
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Mailing Address
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CityStateZip Code
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Daytime Phone NumberFaxemail
Colon Hydrotherapy Course “Intermediate”
Please check the appropriate box:
I wish to register for the following class:
Date:___________________________________________________________________
Personal Information:
Where did you take your basic training?
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Where do you work? ______________________________________________________________________________________________
Are you a member with I-ACT? _______________ ______________________________________________________________________
I was referred to this Institute by:__________________________________________________________________________
Please enclose 6 questions you would like to have covered in the class to help you in assisting your clients:
1.___________________________________________________ 4.________________________________________________
2.___________________________________________________ 5.________________________________________________
3.___________________________________________________ 6.________________________________________________
Do you want to take I-ACT testing? : YES: Level #1 Level #2 NO:
(I-ACT fees not included in registration)
Method of Payment: Total fee $950.00. Please pay the $250 deposit at this time. Remaining $700 due on first day of class.
Check # ________ for $250 is enclosed.
Credit Card (Visa/MasterCard/Discover/American Express)
Credit Card #: ______________________________________________________ Expiration Date:______________
I declare that the above statements are true and correct.
________________________________________________________________________________________________________
SignatureDate
Complete and sign this form and the appropriate Enrollment Agreement and mail with $250 deposit to the above address. Your space in class is saved not only with your deposit but also upon the receipt of your forms.
Balance of $700.00 due on the first day of class.
