R E G I S
T R A T I O N F O R M
DINNER MEETING
____________________________________________________________________________________ |
| Name/Degree
(please print) |
e-mail |
_____________________________________________________________________________________ |
| Address
|
Phone
(include area code) |
_____________________________________________________________________________________ |
| City,
State & ZIP |
License
Number |
TOPIC AND
DATE______________________________________________________________
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I enclose my check
for $40 (Member) |
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|
I enclose my check
for $45 (Non-Member) |
|
|
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|
I enclose my check
for $35 (Student/Intern) |
|
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Check
payable: Southern California Society of Clinical Hypnosis
Mail to:
SCSCH, Marion Arom Ph.D., 1125 S. Beverly Drive, Suite 401, Los
Angeles, CA 90035
Or Call 888-32-SCSCH to
register by phone and pay at the door.
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