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

(____)_____________________________________________________________________________________________________________

Daytime Phone NumberFaxemail

Colon Hydrotherapy Course “Advanced”

Please check the appropriate box:

I wish to register for the following class:

Dates:________________________________________________________

Personal Information:

     Where did you take your basic and/or intermediate training?

__________________________________________________________________________________________________________________

     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     Level#3NO:

   (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.