FORM

Please fill in the following information. All fields are required.

Name and Title________________________________________________________

Company_______________________________________________________________

Street________________________________________________________________

CITY, STATE/ZIP_______________________________________________________

Phone_________________________________________________________________

FAX___________________________________________________________________

Type of course __________________________________________________________

Please mail along with $25 check payable to Palmer Associates Inc.

Palmer Associates Inc.

1840 41st Ave. Suite 102-258,

Capitola,

CA, 95010