Registration Form for February 4, 2012 Class

Registration form for
Speaking Up For Yourself:  A Class in Basic Assertive Communication

Please print this form, fill it out, and fax it to 404-873-4028 or mail it to 

Dr. Linda Tillman

1904 Monroe Dr. NE Suite 200

Atlanta, GA 30324-4860

Date of class:  February 4, 2012
Time:   9 - 12
Cost:  $100

Name:  ______________________________

Address:  _____________________________

               _____________________________

Phone:   _____________________________

Email address:  ________________________

I would like to pay by:

Check  ___  (enclosed)

PayPal ___   Please send PayPal payment to linda.tillman@gmail.com or email me for an invoice

Credit Card ____  We accept Mastercard and Visa
   
     Credit Card number:  ___________________________________

     Expiration date:  _______________   Security code on back: _______