REGISTRATION FORM

COLOUR MIRRORS Practitioner Courses
Color 1 and Color 2

Please make sure we receive this form with your DEPOSIT of $100 for Color 1 or $150 for Color 1 & Color 2 no later than September 25, 2007. Email Us: colourworks@luminanti.com, Fax: 919-563-1522, Mail: Anne Christine Tooley, 4402 Bradford Ridge Rd., Efland, NC 27243. This information is confidential and will be used only by the administration and teachers of Colour Mirrors.

Date: ______________________ Name : ________________________________________________________

Address: ___________________________________________________________________________________

Daytime Phone : __________________ Evening Phone: ___________________ Fax: ___________________

Courses you are attending: __________________________________________________________________

Amount Enclosed: _____________ Email: ____________________________________________________

Payment Method: Visa or Mastercard Debit/Credit Card Money Order Check

Credit/Debit Card Type: VISA MASTERCARD Credit or Debit Card: Credit Debit

Credit/Debit Card # _________________________________________ Exp. Date (mm/yy) _____/_____ CVV2 # ________

SIGNATURE: _________________________________________________________________________

Occupation: __________________________________________________________________________

Professional Skills: ____________________________________________________________________________________

Would you like flyers, letters, etc. sent via email? YES NO

What would you like to learn and experience from these courses? Will you be using it personally, professionally and/or with family & friends? How would you like to incorporate Colour Mirrors into your life and/or practice? How can we be of support in helping your incorporate and use Colour Mirrors?

OPTIONAL (for relating Colour Mirrors to your Astrology Birth Chart): Birth Date (mm/dd/yy) ______________________

Birth Time: _____________ AM PM Birthplace: ________________________________________

EMAIL to: colourworks@luminanti.com ~ FAX to: 919-563-1522
MAIL to: Anne Christine Tooley, 4402 Bradford Ridge Rd., Efland, NC 27243