Register for Infinity Institute Classes On-Line

Please provide the following Registration information:

Items Marked with an * are required

*First Name
*Last Name
*Middle Initial	If none place * in this field
Title
Organization
*Street Address
Address (cont.)
*City
*State/Province
*Zip/Postal Code
*Country
*Work Phone
*Home Phone
*E-mail
URL

Choose one of the following Course options:

Select One Basic and Self Hypnosis Course Advanced Hypnosis Course Hypnoanalysis Course Forensic Hypnosis Course

Choose one of the following Start Date options:

Select One Basic - Start Date Sept 18, 2010 Advanced - Start Date Oct. 16, 2010 Hypnoanalysis - Start Date Nov. 20, 2010 Basic - Start Date Jan. 15, 2011 Advanced - Start Date Feb 19, 2011 Hypnoanalysis - Start Date Mar. 19, 2011 Basic - Start Date May 7, 2011 Advanced - Start Date June 4, 2011 Hypnoanalysis - Start Date July 9, 2011 Basic - Start Date Sept 17, 2011 Advanced - Start Date Oct 15, 2011 Hypnoanalysis - Start Date Nov 19, 2011

Choose one of the following Payment Plan options:

Select One Plan 1 - $140 + Registration Fee ($165) paid 14 days prior to class start date (Save $20 on total tuition) Plan 2 - $140 + Registration Fee, the balance due the first day of class. Plan 3 - $140 deposit + Registration Fee ($165), with half of balance due the 1st day of class, and the total balance due the 1st day of the second weekend of class. Plan 4 - Full Tuition for 120-Hour complete Training paid in advance at great savings. Call Office for details.

I agree to pay Infinity Institute International, Inc., the sum of  $ according to Plan Plan 1 Plan 2 Plan 3 Plan 4 above.

First payment of $ Due on or before the date of  .

(If Required) Second payment of $ due on or before the date of  .

Remaining balance of $ payable on the date of  .

ON-LINE PAYMENT INFORMATION 

I AUTHORIZE Infinity Institute International, Inc. to charge my Credit Card in the amount of $ to be applied toward application and tuition.

V/MC/Disc #      Exp Date Mo/Yr /     CVV# last 3 # on back of card)

Credit Card Billing Street Address and Billing Zip Code

● Required All Applicants - Please read and TYPE IN FULL NAME as it appears on your credit card  – Contract Agreement

CONTRACT AGREEMENT: I hereby certify that all information contained in this application is true and complete. I understand that no certification or diploma will be issued until all financial obligations are met.

Full Name             DATE of AGREEMENT(dd/mm/yy)

COURSE TITLE Select One Basic and Self Hypnosis Advanced Hypnosis Hypnoanalysis Forensic Hypnosis     Start Date of Course (dd/mm/yy)

Confirmation and exact location of classes in the Royal Oak, Michigan area will be sent upon receipt of Application and Tuition fees.