Registration Form
To register, please print and complete this form. Please mail or fax the completed form, applicable deposit payable to Klose Training & Consulting, LLC, and a copy of your professional license/diploma to:

Klose Training & Consulting
1369 Forest Park Circle, Suite 101• Lafayette, Colorado, 80026
toll free in the USA: 866-621-7888 • phone: 303-245-0333 • fax: 303-245-0334

Please note, with your registration you are accepting the student agreement.

Please Note: This form may require more than one page to print.

Please indicate the name, date and location of the course you wish to attend:
Course Name::
 MLD/CDT Certification Course
Course Date:
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MLD/CDT Advanced & Review Course
Course Location:
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Other:
Please complete the following contact information about yourself:
Name:
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Home Address:
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Home City/State/ZIP:
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Business Name:
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Business Department:
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Business / Work Address:
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Business City/State/ZIP:
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Daytime Phone:
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Evening Phone:
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FAX:
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E-Mail Address:

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Please indicate your professional title and enclose a copy of your license/diploma with this registration.

 M.D.
 
P.T.

P.T. A.

O.T.
 
O.T.A.

R.N.
 
M.T.*
Other:__________________

*Massage therapists from the U.S. must show proof of completion of a minimum 500 hours training program or be certified through the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB).

Payment
The total tuition for the course is as outlined on the information sheet for the course of your choice. A deposit (see course information sheet) is required at the time of registration and will hold your spot until the total amount is received two (2) weeks prior to the first day of class.
My check or money order (U.S. Currency) payable to Klose Training & Consulting, LLC is enclosed Please charge my VISA/ MC card in the amount of: $ _________
Credit Card Information


VISA


MasterCard

 Name (as it appears on the card - please print) Card Number
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Signature Exp. Date
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