| Kinessage LLC is approved by the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) as a continuing education Approved Provider. |
| Copyright © 2008-2011 Knead for Balance, Inc. All Rights Reserved |
Print out, fill in and fax this form to 480-907-7401 or
Scan and E-Mail this form to kg@kneadforbalance.com
Class Title_____________________________________________________________
Date and Location (city)_________________________________________________
Name (as it will appear on Certificate)_______________________________________
Billing Address____________________________________________________________
City ____________________________ State __________________ Zip____________
Visa or Master Card Credit Card #_______________________________
Expiration: _________________ 3 digit security no: _________
Name on Card:___________________________________________________
Authorized Signature:_____________________________________________
Phone __________________ Fax (for confirmation)____________________
Email (for confirmation)_____________________________________
If Paypal was used:
Amount Paid Online $_________Balance Due 1st morning of class $_____
Any questions? Email me or call 602.617.9737
Confirmation will be sent by email or fax within three days of receipt. If an email or
fax confirmation cannot be sent, a phone message is left.
I look forward to seeing you in class - Kathleen
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