By Phone	(310) 363-0236
	By Fax	(818) 292-8430
	By Email	info@ipectherapy.com
	By Mail	The Center For Integrative Psychotherapy ATT: Registration 16542 Ventura Blvd., Suite 320 Encino, CA 91436

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Registration form

Registrant Name (as it will appear on the completion certificate) __________________________

Address _______________________________________________

City _________________________________________________

State _________________      Zip ______________

Phone ________________________    Fax ____________________

Email Address (for confirmation)  ________________________________________

Course Name _________________________________________________________________

Amount Paid  ___________________

Method of Payment: 

□    Check Enclosed.  Payable to Dalia Kenig

Credit Card:       □ Visa   □ MC    □ AmEx    

__________________________________________________________________________
Credit Card Number                             Expiration Date                    Security Code           

_____________________________________
Name on Card

___________________________________________________________________________
Authorized Signature                             Print Name                                    Date