Newsum Bio-Kinetics Health Restoration Seminars
P.O. Box 1237
Lomita, CA 90717
www.biokineticshealth.com
E-mail:
execofc@biokineticshealth.com

Print and Mail or Scan and Email Registration Form

Name:
Doctorate:
Office Address:
Mailing Address:
Office Phone:
Home Phone:
Fax:
E-mail:
Graduate Of:
City, State:
Degree In: Year Received:
Techniques I have studied:

Therapies & Techniques I currently use in my practice:

I use these for analysis:
(Please check and/or describe where indicated)
Muscle Test: _____ Leg Length: _____ Arm Length: _____ O-Ring: _____
Other: _________________________ Other: _________________________

Course Date:
Course Location:
Amount: (Check One)

Seminar Registration Fees:
First Time Attendee Seminar Fee includes manual, New-Stim Stimulator with holster, test and assessment charts: $575 _____
Refresher Seminar Fee includes manual: $175
_____


Make checks payable to: Newsum Bio-Kinetics
Check Number: _____    Total enclosed/authorized $________
Credit Card Type: (Check One)
Visa: _____ Master Card: _____ Credit Card 3 Digit Security Code _____
Credit Card Number: Expiration Date:
Name of Cardholder:
Signature: Today's Date:
Special Instructions:
Learned of Seminar: ____ Referral ____ Print Ad ____ or _________________________

* Prices subject to change without notice.