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registration form

HOME> Professional Training> registration form

Copy and paste the form below into an email and then fill out and send.
(copy by clicking and dragging across the form from top to bottom.)

Registration for Professional Emotional Clearing Facilitator Certification


Training Start Date:

Name (As you want it to appear on your certificate):

Sex:

Date of Birth:

Phone: Work & Home:

Skype ID (Can provide later if don't have now):

Address (Where your certificate is sent to):

Credit/Debit Card Info:
Type of card (Visa or Mastercard only):
Card Number:
Card Expiration Date:
Billing Address if dif. from above including zip:

Current Profession:

 

How do you envision using your Certification?

 

Other Professional Credentials / Relevant Life Experience (not req'd for cert.):

 

Anything Else:

 

 

email to: jrusk@emclear.com
Put EC TRAINING in the email subject line

When we get your registration, you will be charged the deposit of $250 (early registration) or $350 (regular registration). We will notify you that your card has been charged and we will set up a phone call with John.

 
 
 

© 2004 John Ruskan / The Institute for Emotional Clearing