PRINT THIS FORM - COMPLETE AND RETURN WITH PAYMENT (see below)


Class Date:________________________ Class Location: _________________________________




Name: Husband_________________________________Wife ________________________________
Last First Last First


Address _______________________________________________________________________________
Apt, Street City, State, Zip



Phone
Husband:______________________________________________________________________________
Home Work Cell

Wife:__________________________________________________________________________________
Home Work Cell



Email _________________________________________________________________________________


FEES: $125 + $5 (Shipping & Handling)

USE ONE OF THESE PAYMENT METHODS:

1. CHECK: Mail completed form with check for $130 to Marriage Communication Workshop, 136 Via Capri, New Smyrna Beach, FL  32169.  Registration closes one week prior to start of class.

2. PAYPAL - FAX completed form to (386) 402-8409 (call first to talk to Mary Beth) and pay $130 with Paypal marybethkoplin@gmail.com.
OR you can scan this filled-out form to marybethkoplin@gmail.com.

Upon receipt of completed form and full payment, your materials will be shipped by US Mail.

THANK YOU! Please call with any questions: Marriage Communication Workshop 443-413-7918, Ed Koplin