Momentum Education... For Life's Possibilities

Workshop Registration Basic Los Angeles
  1. Basic Enrollment Form Los Angeles

    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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  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. Occupation
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  8. Street Address(*)
    Please type your street address.
  9. Apartment Or Suite #
    Please type your apartment or suite #.
  10. City(*)
    Please type your City.
  11. State(*)
    Please type your state.
  12. Zip Code(*)
    Please type your zip code.
  13. Home Phone(*)
    Please type your Home Phone.
  14. Work Phone
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  15. Cell Phone
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  16. E-mail(*)
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  17. Birth Month(*)
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    **Enter your birth Month
  18. Birth Day(*)
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    **Enter your birth Day
  19. BirthYear(*)
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    **Enter your birth Year
  20. I Was Referred By(*)
    Please type who referred you.
  21. Payment Type(*)
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    * Please note for anyone that selects the January 5-8 or January 26-29 Tuition Free Basic, that your credit card number is only to hold your seat and will only be charged a fee of $100 USD if you do not show up for the event or you do not cancel your participation at least 48 hours before the start of the Workshop
  22. Credit Card Type(*)
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  23. Credit Card #(*)
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  24. Expiration Month(*)
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  25. Expiration Year(*)
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  26. CCID #(*)
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    ** 3-4 digit number on the back or front of your card
  27. 1st Goal I Wish To Accomplish(*)
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  28. 2nd Goal I Wish To Accomplish(*)
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  29. 3rd Goal I Wish To Accomplish(*)
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  30. Comments
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  31. Enter Security Code
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  32.   
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