AJ VARGAS ENTERPRISES
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PRINT, COMPLETE AND FAX THIS FORM BACK TO +1 800 314 7618 (from North America) or +34
911 516 322 (from Rest of World). No cover sheet is required - immediately start transmission.
OR POSTAL MAIL TO AJ VARGAS, PO BOX 362, CAPE MAY, NJ 08204 USA.
PLEASE COMPLETE THE FOLLOWING FIELDS (1-19), AS APPROPRIATE. USE ONE APPLICATION FORM PER EVENT, PLEASE.
1. NAME OF THE AJ VARGAS ENTERPRISES PROGRAM FOR WHICH YOU ARE ENROLLING:
______________________________________________________________________________________.
2. DATE(S) BEING HELD: ______________________________________________________________.
3. TOTAL COST OF PROGRAM: ________________________________________________________.
YOUR PERSONAL INFORMATION:
4. Name: ___________________________________________________________.
5. Mobile (Or If No Mobile, Other) Phone:_______________________________.
6. Email: ___________________________________________________________.
7. If a Men's Program, Specify Age (must be over 21): ___________________.
8. For lodging during a residential program, do you wish to share a room with another participant? If so, be sure both participants list one another's NAMES on each registration form:
_________________________________________________________________________________.
9. Also, to the above, if available, do you and your roommate wish separate beds or a shared bed? (Place an "X" by your selection):
______ Separate beds _____ One shared bed
Note: Every effort will be made to accommodate your request, but, depending on the host property, it cannot be guaranteed.
10. Any Special Requests (specify): ________________________________________________
_________________________________________________________________________________.
11. Address: _____________________________________________________________________
____________________________________________________________________.
12. Form of payment (check one): __ Check __ Direct Credit Card (add $10 to Direct Credit Card transaction)
13. Select one (1) of the following two (2) options, A or B:
A. If paying by Check: Mail completed form with your check to: AJ Vargas, PO Box 362, Cape May, NJ 08204. Be sure to note the name and date of the program in the memo section of your check.
OR,
B. If paying by Direct Credit Card (add $10 USD): Complete the following:
14. Name as it appears on card:
__________________________________________________________________
15. Card #:
__________________________________________________________________
16. Exp. date:________________
17. Card type (check one): __ Visa __ MasterCard __ Discover __ American Express.
18. Billing address if different from home address (if same, write "same"):
_____________________________________________________________
_____________________________________________________________
19. Phone # as registered with credit card company, if different from mobile/other number (if same, write "same"):
_____________________________________________________________
FOR DIRECT CREDIT CARD PAYMENTS, FAX OR MAIL THE FORM BACK, TO THE ABOVE FAX NUMBER OR POSTAL ADDRESS AT THE TOP OF THIS FORM.
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A confirmation email with further details will be sent to those registered. Thank you!!
QUESTIONS?
If you need to contact us, go to
http://ajvargas.com and click-on "
Contact Us" on the blue, left-hand bar at the bottom.
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Rev 10 Feb 2011