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HOMESTUDY COURSE(S) APPLICATION
the information below is completely confidential

NAME:____________________________________

PHONE:______________________________

ADDRESS:_________________________________FAX?_________________________________

DATE OF BIRTH:______________________

SEX:______MARITAL STATUS:_______

NUMBER OF CHILDREN: (boys)____(girls)____

PARTNER OR SPOUSES NAME:_____________________________________________________

Which courses are you ordering?
__Tarot Card Reading Course (required for 900 Line applicants) *$135.00*
__Telephone Psychic Counselor Course *$135.00* ($90 if taken with the above)
__Dream Interpretation Course *$135.00 ($90 if taken with one of the above, $70 if taken with both of the above)
TOTAL TUITION DUE:____________
(these are special prices because you plan to work for Spirit Connection)

Your name exactly as you want it to appear on your Certificate
(Most people include their middle name)
________________________________________________________________________________________

Why do you wish to become a counselor/reader?_______________________________________________


List any experience as a counselor (including informal, with family or friends)______________________

_________________________________________________________________________________________________
Your occupation:_______________________________________________________________________


Special Skills:__________________________________________________________________________


Hobbies, etc.?__________________________________________________________________________


Do you pledge to use your Counselor/Reader status for the Service Of Humanity?____________________


Date:________________ Signature:________________________________________________________

Shipping Charges:check one:
___Bookrate (up to 10 days) $2 per course
___Priority Mail (2-3 days) $5 for one, $3 each add'l course
___FedEx (overnight) $15 or more, please call us for exact cost

TOTAL TUITION DUE:_________________
SHIPPING COST:_____________________
TOTAL AMT. ENCLOSED:_______________

METHOD OF PAYMENT:
____CHECK OR MONEY ORDER MADE PAYABLE TO DR. KATIA ROMANOFF

___VISA
___MASTERCARD
___DISCOVER
16 DIGIT CARD #________________________________

NAME ON CARD:__________________________________

EXPIRATION DATE:_______________________________


CARDHOLDER SIGNATURE:__________________________(REQUIRED)

SHIPPING ADDRESS:______________________________________________________________________

PRINT THIS PAGE OUT AND MAIL ALONG WITH
FEE PAYABLE TO DR.KATIA ROMANOFF.
MAIL TO:
DR. DEBBIE HOLDER
213 SCHAERF RD.
SCROGGINS, TX 75480

*****************************************************************************
Please do not write in this space.
Reviewed And Approved By:________________________________________________________

This day ___________________________________
Rec’d On__________________________________

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