Pay by Check for Seminar

REGISTRATION
Paying by Check

Fill out the form first, then print and mail with your personal check to Rod Kochtitzky.
After printing, please hit the submit button to reserve your spot for the seminar.
PLEASE NOTE: You must print and mail the completed form with your check.

MAKE CHECKS PAYABLE TO:
Rod Kochtitzky

Pastoral Center for Healing
1204 Noelton Avenue

Nashville, TN 37204
Phone Message: (615) 385-3838

Your name:

Partner's name:

Address:

City:

State: Zip:

Your E-mail:

Partner E-mail:

Home phone:

Cell phone:

Do you need a notarized certificate of attendance:

This certificate applies to your TN marriage license.

Seminars - Please enter amount ($100): $

You are paying by sending a check.

Please enter the date it will be mailed:

Date of Seminar you want to attend:

How did you hear about this Seminar?

T H A N K Y O U !

Please print this page and mail with check. After printing, please click on the submit button below.