Name:__________________________________________

Address:_______________________________________________

______________________________________________________

______________________________________________________

Module:  1) X-Ray________

               2) Orthotics_________

               3) Structural Management™__________

               4) Muscle Management™__________

               5) Consult/Exam/Re-Exam__________

               6) Report of Findings__________

               7) Psychology of $$$$__________

               8) Communication__________

               9) Writing and Public Speaking__________

              10) Patient Compliance__________

              11) Approaching Sports and Industry__________

              12) “No Problem”__________

              13) Building Your Legacy__________

CC:     Visa     MC     Discover         Amex

CC#:__________________________________________________________

Exp. Date:__________    # of Modules________    S/H  $______________

Total Amount:  $______________                FAX TO: 518.393.2616