First Name: |
__________________________ |
MI: |
__________________________ |
| Last Name: |
__________________________ |
Company/Organization: |
__________________________ |
Name as you would like it to appear on your certificate(s),
if you are ordering a certification program: |
_____________________________________________________ |
| Mailing Address: |
__________________________ |
City |
__________________________ |
| State/Province: |
__________________________ |
Zip/postal code: |
__________________________ |
| Country: |
__________________________ |
|
|
| Daytime telephone: |
(______) ____________________ |
Fax number, if available: |
(______) ____________________ |
| E-mail Address: |
__________________________@____________________________________________________ |
| How did you find us on the Internet?
(Yahoo, Exite, Info Seek, Web Crawler, etc.) |
| What was your search word(s)? |
__________________________ |
|
|
| Credit card, Debit
Card, Bank Check, Money Order, U.S. funds only |
| Account Number: |
__________________________ |
|
|
| Expiration Date: |
______/____________ |
|
|
| CVC Code*: |
___________ |
|
|
| Name on Card: |
__________________________ |
|
|
| Signature |
____________________________________________________ |
First Name: |
__________________________ |
MI: |
__________________________ |
| Last Name: |
__________________________ |
Company/Organization: |
__________________________ |
Name as you would like it to appear on your certificate(s),
if you are ordering a certification program: |
_____________________________________________________ |
| Mailing Address: |
__________________________ |
City |
__________________________ |
| State/Province: |
__________________________ |
Zip/postal code: |
__________________________ |
| Country: |
__________________________ |
|
|
| Daytime telephone: |
(______) ____________________ |
Fax number, if available: |
(______) ____________________ |
| E-mail Address: |
__________________________@____________________________________________________ |
| How did you find us on the Internet?
(Yahoo, Exite, Info Seek, Web Crawler, etc.) |
| What was your search word(s)? |
__________________________ |
|
|
| Credit card, Debit
Card, Bank Check, Money Order, U.S. funds only
(If splitting payment on two cards) |
| Account Number: |
__________________________ |
|
|
| Expiration Date: |
______/____________ |
|
|
| CVC Code*: |
___________ |
|
|
| Name on Card: |
__________________________ |
|
|
| Signature |
____________________________________________________ |
| For fast processing,
mail to:
Certified Personal Fitness Chef
John Spencer Ellis Enterprises, Inc.
30245 Tomas
Rancho Santa Margarita, CA 92688 USA
Make check or money order payable to:
c/o Chef Order
|
For the fastest service,
pay by credit card and fax your application to:
(949) 589-8216
If you have any further questions, please call Toll Free 1-877-573-6474
(1-877-JSE-6474), ext 101
John Spencer Ellis Enterprsises, Inc. |