The C.H.E.K Certification Program

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C.H.E.K CERTIFICATION PROGRAM Notification Form: I am interested in becoming a Corrective High-performance Exercise Kinesiologist
Name		Date
Job Title		Company
Address
Apt.		City
State/Province		Zip/Post Code
Country
Phone		Fax
e-mail
Occupation
Current Certifications
I would like to enroll in the Level I course on: held at:
Yes No I enclose a deposit to secure myplace: US $1500 (Level I Parts A, B, C)
Yes No I enclose a deposit to secure myplace: US$500 (Level I Part A only)
		Name on Card
		Card Number
		Expiration

Yes No I am unable to attend at present, but would like to be notified of any future scheduled courses:
I prefer to be contacted by:
Mail Phone Fax E-mail