Senzar Learning Center Registration Form

    Please print and fill in the registration form. Return it in one of the following ways:

    Fax: Fax to our secure phone number (800) 741-9324 or (928) 204-0594 with credit card information.

   Title(s) of Classes You Want To Register For:

   ___________________________________________________________

   ___________________________________________________________

    ___________________________________________________________

    ___________________________________________________________

    Date(s) of Classes:

    ___________________________________________________________

    ___________________________________________________________

    Total Amount Due:  $_____________

   Please complete name, contact information, and payment method:

    Name _______________________________________________________________________

    Name #2 ____________________________________________________________________

    Address ____________________________________________________________________

    City __________________State _______ Postal Code ___________ Country _____________

    Phone Number ____________________ Email Address _______________________________

    Check enclosed ____________ (amount)

    Credit Card # __________________________________________ Exp. Date ____________

    Name on Card ______________________________________________________________

    Signature __________________________________________________________________

    Credit Card Billing Address if Different than Above:

    Address ___________________________________________________________________

    City _____________________State ________ Postal Code _________Country ___________