Imago Consultation Group
Registration

Registration is a two step process. Step one is to make payment. Step two is to complete the registration form below.

You can pay the registration fees online through Google. You can also remit a personal check or money order to:

Dr. Tony Victor
6 Emerald Terrace
Suite 4
Swansea, IL 62226

When you have completed payment please return here to complete the Registration Form below.

Thank you. We are looking forward to meeting you.

Imago Consultation Group
Registration Form

Please note that all fields followed by an asterisk must be filled in.

Imago Consultation Group
2012 Dates*
Imago Consultation Group
2012 Dates*

	Friday, January 27-St. Louis
	Friday, May 11-St. Louis
	Friday, September 7-St. Louis
	Friday, November 2-St. Louis
	Friday, February 10-Minneapolis
	Friday, September 28-Minneapolis

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Home Phone*
Home Phone*

Business Phone*
Business Phone*

Fax

Special Needs--Comments or Questions

How did you hear about this consultation group?
Who can we thank for referring you to us.

Please enter the word that you see below.

Dr. Tony Victor
618-516-3338

Imago Consultation GroupRegistration