Momentum Education... For Life's Possibilities

Workshop Registration Advanced New York
  1. Advanced Enrollment Form New York

    Thank you for choosing to enroll. Enrolling online will take just a few minutes. Simply fill out this form and submit.

  2. Course Selection(*)
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    Requirements: Basic Workshop Graduate **((includes a $300 non-refundable deposit)
  3. Course Date(*)
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    ** Select a course date shown from the list to the right of your screen.
  4. First Name(*)
    Please type your first name.
  5. Preferred Name
    Please type your perferred name.
  6. Last Name(*)
    Please type your last name.
  7. Street Address(*)
    Please type your street address.
  8. Apartment Or Suite #
    Please type your apartment or suite #.
  9. City(*)
    Please type your City.
  10. State(*)
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  11. Zip Code(*)
    Please type your zip code.
  12. Home Phone(*)
    Please type your Home Phone.
  13. Work Phone
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  14. Cell Phone
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  15. E-mail(*)
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  16. Birth Month(*)
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    **Enter your birth Month
  17. Birth Day(*)
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    **Enter your birth Day
  18. BirthYear(*)
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    **Enter your birth Year
  19. I Was Referred By(*)
    Please type who referred you.
  20. Payment Type(*)
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  21. Credit Card Type(*)
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  22. Credit Card #(*)
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  23. Expiration Month(*)
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  24. Expiration Year(*)
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  25. CCID #(*)
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    ** 3-4 digit number on the back or front of your card
  26. 1st Goal I Wish To Accomplish(*)
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  27. 2nd Goal I Wish To Accomplish(*)
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  28. 3rd Goal I Wish To Accomplish(*)
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  29. Comments
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  30. Enter Security Code
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  31.   
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