May 31, 2017 g9eorge9000 Registration Form Phone Consultation Registration Form Please printout this registration form and complete the information by hand. PLEASE PRINT. Or register by phone 941-922-5277. Print this page Send to: Caroll Michels, Career Coach & Artist-Advocate 1724 Burgos Drive • Sarasota, FL 34238 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): Email Address: Website: 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 Or pay through Paypal caroll@carollmichels.com 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.