Psychotherapy, Spirituality, and the Evolution of Mind

An Interdisciplinary Symposium

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Registration

To register, please mail or fax (if paying by credit card) this form to:
CIPET, 1100 Glendon Ave., #1751, Los Angeles, CA 90024
Phone: (619) 565-9921 || Fax: (619) 565-9954 || E-mail: praxes@worldnet.att.net

Name: ________________________________________________ Degree ________

Address: _____________________________________________________________

City: _____________________________________ State ______ Zip _____________

Phone: (____) _________________________ Fax: (_____) _____________________

E-mail _______________________________

Profession: ____________________________ Prof'l. License No. _______________

____ Main Conference, May 15-17, 1998	$225.00
____ Post-Conference Clinical Workshop (May 18, 1998)	$60.00
____ Continuing Education Certification	$10.00
____Early Bird Discount (postmarked before March 15, 1998)	- $25.00
____ Tricycle Exchange Member Discount	deduct $25 from main conference fee and enclose proof of membership)
TOTAL ENCLOSED:	$ ________

Refund policy: Refund requests must be submitted in writing and postmarked by May 1, 1998.
A $25 handling fee will be deducted.

Method of Payment:

____ Check or Money Order Payable to CIPET

____ Mastercard ____ Visa

Card Number __________________________________ Exp. Date _____________

Card Holder's Name (please print) _________________________________________

Card Holder's Signature ________________________________________________

____ Cannot attend, but please add me to your mailing list.