May 31, 2017

Registration Form

Phone Consultation Registration Form

Please printout this registration form and complete the information by hand. PLEASE PRINT.

Caroll Michels, Career Coach & Artist Advocate
1724 Burgos Drive • Sarasota, FL 34238
Phone: 941-922-5277 • Fax: 941-922-5278

I would like to arrange an initial phone consultation.

First Name Last Name:

Address line1:

Address line2:

City State Zip Code or Postal Code:

Country:

Phone (include area code):

E-mail Web site URL:

The best day(s) of the week for a phone consultation are:
Monday Tuesday Wednesday Thursday Friday
The best hours (Eastern Time) for a phone consultation are:

____________________________________________________

Enclosed is a check for $100.00 representing a deposit for an initial phone consultation, which is prorated on the basis of $200 an hour.
Please charge my $100.00 deposit for a phone consultation to my credit card:
American Express Mastercard Visa

Credit Card Number Expiration Date:

Exact Name of Credit Card Holder:

Exact Billing Address on Credit Card:

Attention Artists Living Abroad:
If you are not charging the deposit to a credit card and do not have an American bank account, please use one of the following methods of payment:
Enclosed is a bank draft for $100.00 in U.S. dollars paid out to an American bank for an initial phone consultation
Enclosed is an international money order or American Express money order for $100.00 U.S. dollars for an initial phone consultation
* Please note: Canadian postal orders are not accepted.

Privacy Notice:
Please be assured your name and personal information will never be rented, sold, or otherwise distributed to anyone, for any reason.