Divas Weight-Loss & Health, Plus
Registration Form
Workshop/Meeting Date__________
Name ______________________________________
Address______________________________________
______________________________________
H-Phone ____________________________________
W-Phone ____________________________________
C-Phone ____________________________________
Email Address: _______________________________
Payment :
___100.00 For Extreme Weight-Loss & Health Workshop only
___250.00 For the Serious and Sensational Package
___150.00 for Chart your Course Package
___Other Authorized Package/Amount _________
Check or Money Order
Please make check or M.O. out to:
Divas Weight Loss
9626 Axehead Ct., Suite 201
Randallstown, MD 21133-2611
Atten: Alicia Fieldings
Credit Card
Number ______________________________________
Exp. ___________Signature *Code ______________
(*3 digit code listed on the back of your card, generally on the signature strip)
Signature X_____________________________________
Please fax your credit card information & registration to: 303 496 8454
