Getting the Love you Want
Couples Workshop
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.

Getting The Love You Want
Couples Workshop
Registration Form

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

Getting The Love You Want
2012 Workshop Dates and Locations*
Getting The Love You Want
2012 Workshop Dates and Locations*

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*

Contact Phone*
Contact Phone*

Partner First Name*
Partner First Name*

Partner Last Name*
Partner Last Name*

Partner E-mail Address

Partner Street Address*
Partner Street Address*

Partner City*
Partner City*

Partner State/Prov*
Partner State/Prov*

Partner Zip/Postal Code*
Partner Zip/Postal Code*

Partner Contact Phone*
Partner Contact Phone*

Choice of beverage. Check all that apply.

Partner's choice of beverage.
Check all that apply.

Special Needs--Comments or Questions

How did you hear about this workshop?
Who can we thank for referring you?

Please enter the word that you see below.

Dr. Tony Victor
618-516-3338

Getting the Love you WantCouples WorkshopRegistration